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A new clinical trial demonstrates that
identifying and overcoming three barriers greatly improves the
quality of hemodialysis treatment, a finding that may help the
33,000 Americans now receiving suboptimal doses of hemodialysis.
According to an article in the April 17
issue of The Journal of the American Medical Association
(JAMA), the three barriers are under-prescription of dialysis
by physicians, use of intravenous catheters to provide treatment
and shortening of treatment time by patients. The randomized controlled
trial showed that educating physicians and patients about these
barriers resulted in a two-fold larger increase in dialysis dose
compared to conventional care.
The study's method of identifying and overcoming
barriers to quality care may also be applicable to other chronic
conditions such as asthma or heart disease.
Virtually all dialysis treatment is paid
for by Medicare, even for patients younger than 65 years old.
Despite annual federal expenditures of $18 billion, the mortality
rate among American hemodialysis patients is the highest in the
industrialized world at 23 percent per year. European and Japanese
hemodialysis patient mortality rates are much lower at 10 to15
percent per year.
The high mortality rate among American
patients is in part due to the fact that one-sixth of the 200,000
Americans receiving hemodialysis treatment do not receive an adequate
dialysis dose. Hemodialysis is used to treat people with kidney
failure. In the process, blood is removed from the body and pumped
into a machine that filters out toxic substances from the blood
and then returns the purified blood to the person.
The researchers, led by Ashwini Sehgal
from the School of Medicine identified three barriers to adequate
dialysis, showed that it is possible to overcome the barriers
and demonstrated that overcoming barriers resulted in higher quality
treatment.
The study, involving 169 patients from
29 hemodialysis facilities, identified and addressed each barrier
separately. If dialysis prescriptions were too low, a study coordinator
helped physicians improve the prescriptions. If patients received
treatment through a catheter, the study coordinator helped patients
get grafts or fistulas instead. A graft or fistula is a surgically
created connection between an artery and a vein that provides
a better blood flow for dialysis. If patients shortened treatment
time by coming late or leaving early, the study coordinator educated
them about the importance of staying for their full treatment
time.
"Dialysis is similar to drugs in that both
must be given at an appropriate dose to be effective," said Sehgal.
"Patients getting an inadequate dialysis dose die sooner and are
hospitalized more often."
The federal reimbursement system, which
provides a fixed payment per treatment, may act as a financial
disincentive to providing high quality treatment.
"Using higher efficiency machines or increasing
treatment time costs money, but facilities don't get paid more
for these higher costs,""said Sehgal. "I urge patients to stay
for their full treatment time," said Sehgal. "I urge physicians
and dialysis facilities to address the three barriers we identified.
I urge policy makers to re-examine how we pay for dialysis treatment."
The cost of carrying out the intervention
was very modest because a single study coordinator educated physicians
and patients. Similar inexpensive interventions might be developed
to identify and overcome barriers to quality care in other medical
areas, said Sehgal.
Sehgal is an associate professor of medicine,
biomedical ethics, and epidemiology and biostatistics at CWRU
and a member of the Division of Nephrology at MetroHealth Medical
Center in Cleveland.
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