Back in 1989: a U.S.-led conference held in Dallas focused on the persistent rise in mortality among dialysis patients. Clinicians in the United States thought it was a worldwide problem. Experts from other countries came and brought their data. The conclusion: the 20% mortality rate in the U.S. was not shared by other countries. It was something we were doing wrong. Everyone went home.
It happened again last month during the Annual Dialysis Conference. We got served by the Canadians this time over our acceptance of a twisted definition of “quality care” in this country. I guess we didn’t learn our lesson.
Much of the history of dialysis care, and transplant, can be traced to American roots: The first outpatient dialysis clinic in Seattle in the 1960s that helped keep Clyde Shields, a machinist, alive for 11 years; access innovations by Scribner, Babb, and Quinton. Even the Life and Death Committees, while not a bright spot in health care allocation, did their best to determine how to dole out a scare resource.
But despite those achievements, there are few countries today that would emulate our approach to renal replacement therapy.
Does anyone find this embarrassing?
Nephrologist Joanne Bargman offered some ideas during her Steven Vas Memorial Lectureship at the ADC. The title of her presentation, “Buffing the numbers: The decline and fall of dialysis medicine” zeroed in on how success is measured today in the U.S. kidney community: achieving points on a government-driven scorecard. She reminded everyone in the lecture hall what the original belief was for the ESRD Program: “In 1972, President Nixon and Congress believed treating dialysis patients would cost about $35 million a year, but most of that would be offset by everyone going back to work and being productive.”
That hasn’t happened. But other things have, said Bargman: the establishment of large dialysis companies that, she says, “have their hearts in the right place” but have taken away the autonomy of doctors and nurses, and “enslaved” everyone to government-imposed targets.
And many people cheat to meet those targets and save their employer that sacred 2% “incentive “ that the Centers for Medicare & Medicaid Services offers in its Quality Incentive Program if clinics churn out numbers that show they are in compliance.
Bargman then went through a series of antedotes – comments from staff at U.S. dialysis clinics – telling her how they cheat: “We list our grafts as fistulas. No one checks it.” Lab tests are done repeatedly–before and after dialysis – to get the Kt/Vs that staff need to meet the QIP requirements.
By now the audience is reacting with disbelief, mixed with nodding heads and moans and groans about what their fellow clinic staffers would do to just to meet the demands of the QIP.
All this cheating flows into a dismal enthusiasm for the profession itself in the U.S., notes Bargman. A Medscape-directed survey among physicians found that only 43% of nephrologists said they would pick the same profession again. Fellowship programs have empty slots to fill. “If you have a pulse, you can get into the program,” said Bargman.
People in the audience—nephrolgists, nurses—laughed. Doesn’t anyone find this embarrassing?
And patients? Many now say they wouldn’t go on dialysis again, said Bargman.
No one laughed.
Bargman concluded her talk by suggesting to the audience that U.S. dialysis care needs to change; the renal community needs to take charge of defining what quality looks like. Government entities need to back down.
She was met by a standing ovation.
'We can do better.' –– Belding Scribner
So where is the American renal professional with this “Go get ‘em” attitude? Why can’t we find an inspired leader to bring about change? Why have we accepted the notion that dialysis quality is dictated by your “total performance score?” The federal government is a major payer for dialysis. We know that. But governing how quality is measured belongs in the hands of clinicians, not government entities.
Bargman is a staff nephrologist at the University Health Network and Professor of Medicine at the University of Toronto. The Canadian health care system has its flaws. But in Canada:
- There is no Quality Incentive Program that requires dialysis centers to meet government-mandated quality measures
- 30% of patients are on a home therapy. A couple of U.S. dialysis providers come close, but most do not.
- A nephrologist doesn’t get paid more or less based on the modality choice they help choose with the patient. They are salaried and aren’t incentivized by bonus payments or a better monthly capitated payment for one therapy vs. another. They don’t invest in dialysis clinics, so there is no concern about whether the in-center unit is trying to fill two empty chairs on the second shift.
- They use a lot of catheters in Canada – a no-no under our QIP – but dialysis staff have learned to manage the shortcomings and limit infections.
As I have said before in this column, there are many, many hard working renal professionals in this country. But the CEO of your dialysis company is not providing direct patient care. YOU are. If you are with a dialysis provider who makes efficiency a higher priority than delivering quality care, find one who doesn’t. Cheating on your QIP score sheet does little to improve that endpoint.
Take up Dr. Bargman’s challenge—remember what Scribner, Quinton, Babb, and others accomplished on these shores 50 years ago. And let’s not get served again.