HemoDoc, From Doctor to Patient

Prop 23: Patient Safety or Unionization Blackmail?

It is very infrequently that I side with the dialysis industry against patient initiatives to increase safety. Yet, that is the ironic position I find myself today in accord with both Fresenius and DaVita standing against CA Prop 23.

California Proposition 23, Dialysis Clinic Requirements Initiative (2020)

What would this ballot initiative require of dialysis clinics?

The ballot measure would require chronic dialysis clinics to:^[1]

• • have a minimum of one licensed physician present at the clinic while patients are being treated, with an exception for when there is a bona fide shortage of physicians;
  • report data on dialysis-related infections to the state health department and National Healthcare Safety Network (NHSN);
  • require the principal officer of the clinic to certify under penalty of perjury that he or she is satisfied, after review, that the submitted report is accurate and complete; and
  • provide a written notice to the state health department and obtain consent from the state health department before closing a chronic dialysis clinic.

The ballot measure would also state that a chronic dialysis clinic cannot "discriminate with respect to offering or providing care" nor "refuse to offer or to provide care, on the basis of who is responsible for paying for a patient's treatment."^[1]

In an opinion journalism piece on Prop 23, Politico correctly characterizes this initiative as a ploy for forcing unionization in CA dialysis centers:

California's $100M dialysis battle comes with ancillary benefits for labor union

“The whole idea of using non-traditional tactics to achieve greater leverage in unionizing has been around for years,” SF State’s Logan said. “SEIU, in particular, is one of a number of unions that have used corporate campaigning very extensively and quite successfully over a number of years.”

SEIU-UHW, since 2012, has filed some 23 local and state initiatives. In recent years, they’ve launched a flurry of measures, targeting a number of California hospitals to limit prices and impose executive salary caps, though many failed to qualify or were abandoned.

While there are many clinical, political, ethical and legal issues that are unsettling in the dialysis arena, Prop 23 is not the fix for what ills this industry. It is of benefit only to the unions who are proposing these untenable restrictions and impositions. Obviously with a nationwide shortage of nephrology fellows in training, the provision of placing a physician on site while patients are in the treatment area is simply unnecessary, poor utilization of the limited nephrology providers and are simply a blackmail tactic on the part of SEIU to force unionization in dialysis centers. This would paradoxically decrees funds available for patient care given the fixed budgeting with Federal caps on Medicare payments under the Dialysis Bundle.

Further, even ICU's do not require on site physician coverage in the ICU itself. It is the well trained and very capable ICU nurses that are present at all times with doctors available by telephone 24 hours a day and backup coverage with physicians in the ER and hospitalists to assess and manage acute emergencies. Even here, an attending physician on site is not required or necessary. Dialysis patients are by and large much more stable on any given treatment day than ICU patients. Further, the regulatory requirements for crash carts in dialysis centers are remarkably deficient and do not have standard code medicines present in hospital crash carts or even clinic crash carts we had at Kaiser which were complete. Having a physician on hand in a dialysis center is even more absurd since they would have to wait for paramedics to arrive to have access to even basic ACLS medications used to abort common heart arrhythmias or treat acute myocardial infarctions. Doctors on site could provide no more advanced care than the nurses or technicians already on site.

In addition, health reporting mandates are already part of Medicare and state health guidelines. 

I would urge dialysis patients in CA to vote NO on Prop 23 but continue to seek true reform and innovation in dialysis which is desperately needed in this industry. This is neither true reform nor innovation. It is exactly as Poltico correctly states, a ploy by these powerful unions to force the dialysis providers to the negotiation table.

Noncompliance: A Word that Kills

In February 2007, I entered the arena of in-center hemodialysis as a brand new hemodialysis patient. Despite nearly 20 years of experience in hospital and clinic settings, I soon found that it was indeed a brave new world I had entered which was completely foreign to anything I had experienced as a physician. Despite my intention of one day performing home hemodialysis as my preferred modality, I had to submit to the regimented perils of usual care hemodialysis giving my care over to nurses and technicians that I soon learned were overworked and underpaid.

But the biggest culture shock was the manner in which choices were made for me and often without any input from my own wishes. Any patient experiencing the shock of a devastating medical condition can be overwhelmed by the changes in their life and mine were literally overnight going from my clinic the day before to their clinic the next day. Fortunately, I had several years of slowly progressing chronic kidney disease to come to terms with the eventual need for renal replacement therapy. Interestingly, I didn't struggle with that aspect, but the loss of freedom and choice soon became apparent from just obtaining a "seat" in the unit. Most appointments prior to this, I was given choices of times and dates to accommodate my own schedule. Here, I was told when to arrive, what days to come and where to sit.

By God's grace, my technician had gone from being my own patient to my technician overnight as well. She is a talented and dedicated health care professional who mastered the tasks of dialysis with compassion and competence as few other techs have. I was pleased to later learn that she had proceeded to an RN program to complete her education. Fortunately as well was our prior relationship of trust and respect so that she felt comfortable listening to my concerns. My first decision that she agreed completely was to limit my ultrafiltration (UF) from the very first day to only 500 ml since I still had robust residual urinary function. I did not understand that day we had violated an antiquated minimum UF rule of 300 ml/hour of dialysis. Yet it made no sense to pull 1200 ml when I had to struggle to make it through that 4 hour session before I got up and went to the bathroom. In fact, there was more than one occasion in my early days of dialysis that I had to pause the treatment to relieve my bladder. That one decision turned out to be an important survival choice which studies confirmed at least a decade later. High UF rates damage residual renal function.

Unfortunately, my wonderful first technician left only a few months later after other techs started vicious and unfounded rumors about her. My safety net collapsed and the real arena of control and retaliation soon followed not even prevented by "MD" after my name. My UF goals of only 500ml and the urban myth of a minimum UF rate persisted and many times over the years, nurses forced me to accept the minimum UF rate and receive 400-600 ml of saline in support. I finally put this to a rest only a year ago by a doctor's order but that still caused one nurse to give me an extended lecture on why it was wrong. After nearly 14 years of hemodialysis, my UF last night was once again, 500 ml for 5 hour session at a UFR of 100 ml/hr and 0.1 kg less than my end dialysis weight two days before. But this took more than a decade to get as a standing order when it should have been done a priori given my lack of significant interdialytic fluid gains even with the loss of most of my residual renal function the last few years.

For such a minor issue to persist for well over a decade despite medical studies showing it is an urban myth, and my own personal situation of not needing even the "minimum UF" settings on most sessions, that was a minor nuisance turned into a major point of contention by all too many dialysis nurses and technicians. The label of me being a "difficult" patient surprised me since it had been my practice and my professional ethics to honor informed decisions by my patients when it was medically indicated or not prohibited. 

The real culture shock which took only a short time to understand was the lack of respect for patient autonomy and the nearly complete lack of informed consent on various choices. (here, and here) One study in 2005 showed that only 12% of patients heard of home hemodialysis as an option before starting renal replacement therapy. Paternalism rules in the dialysis arena from the nephrologist down to the dialysis techs. Further, this culture fuels retaliation I believe much in the same manner psychologically as the Stanford prison experiment produced harsh treatment and control by the the student "guards." Autonomy and choice are squelched by the ever present rushed schedule and lack of time for individualized care from harried techs.

An example of this is when I chose to forgo erythropoietin (EPO) early in my dialysis journey after I learned about the many risks with little if any benefit since my Hb was near normal without any Erythropoiesis-stimulating agents (ESA) support. The first day I declined EPO, the head nurse was very upset with my decision, but the very next day, the FDA released a black box warning and my decision to forgo EPO presaged the new guidelines by one day. Nevertheless, a year later, in 2008 during my first trip to visit my mother in Cape Cod, the clinic director introduced herself with the following statement, "So, you refuse EPO." This after the black box warning and having a Hb over 12.5 without it.

Whenever I declined a treatment or a procedure, it was documented as "patient refuses." Their obvious documentation practices  deliberately made all of my well informed decisions appear to be "noncompliance." When ever I saw that they documented my choice as patient "refuses," I corrected them and stated, no, that is not true. I decline that treatment by a very informed choice based on my study of the issue at hand. Most patients do not have a medical degree and the ability to readily research issues for their own benefit, although a surprising number of my own patients did just that and brought me articles I was not aware of adding to my own education on select conditions.

But this adverse documentation has a purpose in the dialysis industry to justify involuntary dismissals for alleged noncompliance. Involuntary dismissals are a death sentence brought on often by only asking a nurse or technician to wash their hands before treating them.  While the overwhelming number of dialysis professionals are caring, compassionate and competent providers, I have unfortunately encountered far too many who would have fit in well with the SS more so than with Florence Nightingale. In 2018, I became the object of such a cabal of technicians, nurses and a physician who on April 16, 2018 dismissed me involuntarily from my home dialysis program. My doctor claimed I had "failed" home hemodialysis after the technicians claimed that they could not fix what ever was wrong with the machine causing a horrific taste and associated symptoms during dialysis.

Yet, the machines that these techs claimed could not be fixed are the same exact RO and [email protected] machines that my current technician did rebuild and restore to excellent function. My two years of forced in-center treatments came about in part by a campaign to show I was not only noncompliant, but also unable to tolerate home dialysis treatments implying in many ways I was either deficient psychologically or incompetent to run the machine. I am grateful that the atmosphere changed greatly after President Trump's executive order in 2019 to increase home dialysis availability and use in the ESRD population. I doubt I would have returned to home hemodialysis without his intervention.

During my fixed in-center schedule from April 2018 until May of 2020, I missed many family outings especially with my grandchildren such as piano recitals, school outings, and family dinners. This is of minor consequence compared to an in-center dialysis patient who is left with no recourse but emergency dialysis from the ER a few times a month instead of thrice weekly. It is a painful, and slowly agonizing death sentence for the alleged "crime" of noncompliance with the dialysis nurses and administrators acting as their accuser, prosecutor, judge and jury. The ESRD networks often rubber stamp these dismissals leaving the patients with no recourse unless they can get placement with another dialysis. But the dark secret of dialysis centers is blacklisting the dismissed patients preventing transfer to any other unit.

This in part happened in my case as well. The week before I was dismissed, I sought a transfer to another physician at another unit in Spokane WA where I trained on the Baby K. On Friday morning, my doctor I was transferring from called me to ask me if I was going to come in for my monthly clinic visit the next Monday morning. I told her yes and it was my plan to thank her for all she had helped me with over the prior three years and part on a professional and amicable level. She contacted the doctor I was attempting to transfer to who had at one point been a colleague of hers in another medical group. When I came in Monday morning, I thanked them for all that they had done. Then my doctor informed me that the other doctor would not accept me as a new patient but he did agree to a second opinion. All this occurred with the other doctor never once contacting me directly. She further stated that since they could not detect or find the offending issue with my dialysis machines, that I had "failed home hemodialysis" and she was transferring me back to in-center "permanently" the very next day.

I was given no choice, no recourse and they pronounced my sentence. I still acted in a professional manner as a physician and I still thanked her for all that she had done for me the last 3 years. I parted peacefully, cordially and professionally despite the obvious injustice of what had just occurred.

The next two years were difficult and I am still not returned to the level of function I had before this occurred. At 62, it may in part simply be the aging process, but there is no doubt that my body took a toll going from 22 hours of dialysis weekly to 12 to 15 hours a week in-center.

The word noncompliance is tossed around in medical circles as if it is the greatest of evils, yet in my instance, it was simply my own choices, my own informed decisions that was forbidden in this arena of dialysis. And I do call it an arena because anyone that wishes to maintain autonomy, independence and informed choices must become a defensive soldier able to defend those rights themselves, through knowledge, to keep those civil rights so easily dismissed and trampled by this industry.

It is with great sadness that I contemplate the number of patients who have succumbed to this sentence of judgement, this death sentence imposed often for no reason other than the power and control of people imposing their will on others helpless to oppose them. Yet, this is most often a silent suffering only known to those close to these patients. Government statistics are sparse at best. It is time that this practice is halted and true patient rights are respected once again in the dialysis unit.

Belding Scribner commented on his "Nobel experiment" that was hijacked by greed and profiteering. His close friend  Christ Blagg, MD eulogized him after his death in the prominent renal journal CJASN:

Belding Hibbard Scribner—Better Known as Scrib

Christopher R. Blagg

CJASN December 2010

"Scrib was always interested in the big picture. In 1961, he was espousing development of dialysis centers but progress was slow. By 1965, he had seen the success and cost savings with home hemodialysis and was urging its use to enable more patients to be treated. Senator Henry Jackson, who had a childhood friend on dialysis, introduced the first legislation for government support of dialysis and transplantation in 1965. Scrib's views were also a major influence on the Gottschalk Committee that looked at the potential role of government in 1967. He, among others, helped to get Congress to pass legislation for the Medicare End Stage Renal Disease Program in 1972, but later became disillusioned as he saw the large profits in the early years and the growth of for-profit dialysis organizations. He said that what he had regarded as “a noble experiment” had become a vehicle fueled by greed rather than concern for providing the best treatment for patients. He continued his interest in renal politics for the rest of his life."

May it be soon that we return to the ideals of Dr. Scribner's "noble experiment" and see the fruit of his dedicated contributions and donations to all that suffer from renal disease. It is time to overcome greed and cold hearted adherence to the bottom line and instead place relief of suffering and restoration of health and life from this wonderful technology that sustains me today. It is time to see that dialysis is also and in many ways most importantly, the true gift of life.

NxStage Aluminum Contamination: Is Rockwell Medical Inc. at Fault?

By Peter Laird, MD

On May 14, 2014, NxStage Medical Inc. issued a voluntary FDA recall of 140,000 to 150,000 concentrated dialysate SAKs from elevated levels of Aluminum in lots manufactured from April 2013 to February 2014. NxStage produces the only FDA approved portable home dialysis machine and is a popular choice for many patients who wish to maintain an active and independent lifestyle.

To date, NxStage has not revealed details on how this significant failure occurred. I recently discussed the aluminum event with a high ranking NxStage officer who stated that they are constrained by FDA regulatory provisions that prohibit full disclosure until the FDA investigation is complete.

NxStage outsources all of their lactated dialysate products to two companies, PiSA, the largest pharmaceutical group in Mexico and Rockwell Medical Inc. which signed an agreement with NxStage on March 8, 2013 to produce concentrated dialysate. Shortly after this agreement, the first contaminated lots of concentrated dialysate contaminated with high levels of aluminum appeared in April 2013. Many patients allege that Rockwell new to the NxStage lactated dialysate manufacturing process is the likely source of the contaminated concentrates.

Rockwell Medical Inc. produces mainly bicarbonate dialysate in competition with Fresenius dialysis products for the American dialysis market. Incorporated in 1995, my review of  Rockwell public records reveals that this company has limited experience with lactate dialysis products which are produced in a  complex process through fermentation.

The largest producer of lactate products in the world is Purac which has exceptionally low tolerances for aluminum and heavy metals. Purac manufactures pharmaceutical grade lactate with a max tolerance of 0.1 ppm (0.11 mcg/L) and is considered the gold standard producer of lactate products through out the entire world. In an extensive review of NxStage, Rockwell and PiSA public records, none of these documents listed the source of their lactate products, nor could I find direct agreements in public records with Purac. In addition, Rockwell has not responded to date to my queries for comments on this event.

While NxStage will not confirm that Rockwell is the producer of the tainted product, circumstantial evidence points directly to Rockwell as the source. 

Should the FDA investigation conclude that Rockwell Medical is the source of the NxStage Aluminum contamination, investor relations may suffer in light of what many consider a solid future for this company nearing completion of a New Drug Application for their iron dialysate product, Triferic.  It would also mark continued safety and quality concerns that has haunted Rockwell over the last several years.

In 2008,  state inspectors at a South Carolina Rockwell plant found major safety and manufacturing violations in follow up to multiple customer complaints. (here) In 2009, thousands of cases of shipped dialysate was recalled after finding excessive levels of bacterial growth. (here and here)

In 2012, Dr. Richard Yocum,  a former Rockwell senior vice president in charge of Rockwell's Triferic research alleged SEC reporting violations and fraudulant claims for their drug in development in a wrongful termination lawsuit. (here)  Triferic is expected to soon enter an annual 700 million market for iron replacement. Although Rockwell prevailed in this lawsuit, the judge limited his ruling to the narrow question of whether Rockwell had the right to terminate Dr. Yocum's "at will" employment. (here) A private law firm initiated a secondary investigation into these allegations in 2013. (here) 

With the ready availability of high grade, ultra-pure lactate products from Purac with levels at a fraction of those found in the NxStage lactate concentrated dialysate, the ensuing FDA investigation needs to uncover all of the details of this preventable event. However, should Rockwell Medical Inc. become the focus of this active FDA investigation, many will rightly, I believe, question their dedication to quality products.

In light of the impending FDA approval of Triferic after exhuberant results in their recent PRIME study, I myself will take the advice of a trusted colleague who once told me, don't be the first doctor to prescribe a new drug, nor the last. Until we have extensive evidence from Triferic's post marketing results assuming it will soon be approved, I certainly will not be one of the first patients seeking this companies new drugs.

Is Daily Dialysis Dangerous?

By Peter Laird, MD

Kidney International recently published a study on daily dialysis alleging worse outcomes for patients on daily in-center dialysis as compared to conventional in-center thrice weekly dialysis. The authors noted that this was a different outcome than prior observational dialysis studies on more frequent and longer duration strategies.

A multinational cohort study of in-center daily hemodialysis and patient survival

Those receiving daily hemodialysis had a significantly higher mortality rate than those receiving conventional hemodialysis (15.6 and 10.9 deaths per 100 patient-years, respectively: hazard ratio 1.6). Similar results were found in prespecified subgroup and sensitivity analyses. Unlike previous studies, we found that in-center daily hemodialysis was not associated with any mortality benefit. Thus, decisions to undertake daily hemodialysis should be based on quality-of-life improvements, rather than on claims of improved survival.

The researchers conclude that their study is the most conclusive and best evidence on mortality of daily dialysis in-center. However, simply reviewing their methods and results brings into question several areas of concern with this latest publication.

First, the most obvious data needed to compare the patients in this cohort is the clinical indication for why they were on daily dialysis in the first place. While daily dialysis at home is a utilized in the United States and more widely in Europe and Australia, even in those nations, daily dialysis in-center is not ordinarily utilized without specific clinical reasons. In America, many patients who are failing on conventional thrice week therapy often advance to four times a week treatments or more as a rescue strategy. Incredibly, this study failed to gather any data on why patients were on daily dialysis in-center and they indicated informally that rescue may have been an operative indication:

A multinational cohort study of in-center daily hemodialysis and patient survival

Most importantly, we do not have any information as to why daily hemodialysis was prescribed to individual patients in this study. If daily hemodialysis was prescribed as a ‘rescue’ option, patients selected for this therapy may have been sicker than those maintained on conventional dialysis. Some French patients may have been selected in this way (personal communication, CC and RG).

In addition, the short daily group had twice as many grafts compared to the conventional group and 30% of the short daily patients had no access data at all. Given the significant risk of death from AV grafts compared to fistulas, this could lead to significant confounding bias. Other data lacking in this study included no documentation of residual renal function, severity of co-morbid disease or socioeconomic factors, all of which are known predictors of survival. 

In addition, a secondary analysis of the FHN short daily and nocturnal studies by the same lead author focused on access issues speaks negatively of daily dialysis in yet another study:

Risk of Vascular Access Complications with Frequent Hemodialysis

In conclusion, frequent hemodialysis increases the risk of vascular access complications. The nature of the AV access repairs suggests that this risk likely results from increased hemodialysis frequency rather than heightened surveillance.

Many are already discouraged from recent studies and negative commentaries on daily dialysis. Others that know and understand the benefits of daily dialysis and will simply ignore this latest study:

Despite the risks of more frequent dialysis, I will continue, thank you

Studies like this, in my humble opinion, do more harm than good. Some doctors would potentially be put off by this risk of access problems and not recommend more frequent dialysis for their patients. The benefits of the modality are mentioned only in passing and the entire focus of the paper is access problems. This may be all right when you look at it purely from a statistical perspective. But I am really worried that the paper might have just taken daily dialysis off the menu for some people about to get onto dialysis.

That is sad, indeed.

I agree with Kamal Shaw except in one regard. I don't believe that this author in two separate studies has truly proven that more frequent hemodialysis has higher complications and higher mortality. Yes, indeed, that is the conclusions of her two articles, yet can we discount all of the positive articles that have come before? A noted deficiency of the FHN articles is that they did not report whether they used constant site cannulation, better known as buttonhole cannulation which has a lower risk of stenosis and aneurysm, but may increase infections in an in-center setting.

Blood flow rates were not noted in either of these studies as well. Unfortunately, a common practice of many dialysis nurses with short daily dialysis is to significantly increase the blood flow rate to the maximum allowable levels. This is a known cause of access complications that is entirely preventable, but many nurses and patients increase the blood flow rate to improve solute clearances and reduce the time of dialysis. Unfortunately, this data is lacking as well.

I have now completed six full years of hemodialysis and by God's grace and mercy, I have yet to have any access complications. I am now completing nearly 4 years on continuous home hemodialysis with 5-6 cannulations each week. More than once, dialysis professionals have commented that my fistula is the "prettiest" fistula that they have seen.

It is clear when you evaluate the causes of access failure and complications that technique is paramount to assuring reduced adverse events. Taking care of an access requires time that most dialysis technicians simply do not have. It takes me about 20 minutes to remove my scabs, control any bleeding and place betadine, let it dry and remove the excess with alcohol pads prior to inserting my own needles. Most techs simply apply the disinfectant, wipe off any excess and stick a needle into the fistula in less than a minute for both, perhaps two minutes in some cases.

Buttonhole cannulation does not lend itself to that type of rapid access cannulation. What puzzles me the most is the number of nephrologists who actively seek to prove daily dialysis inferior. Is it not time that we enter the rest of the realm of medical practice where we seek to avoid complications, improve procedures and improve outcomes? Sadly, in my opinion, much more effort is generated to discouraging patients from seeking home daily hemodialysis than promoting this wonderful modality.

In my opinion, having God's blessing of no complications from my dialysis to date, frequent daily hemodialysis is easy and safe to administer. I have no doubt that the technical difficulties that in-center patients suffer causing many of these complications are easily correctable but they must have time to do so. It never ceases to amaze me how little the so called dialysis professionals in-center understand about home hemodialysis and commonly used home dialysis techniques.

The better question to answer and promote is why is it that some patients can secure their access without any significant complications for decades, yet some in-center patients suffer frequent episodes of these "common" complications. It is with great regret that I have come to understand that a large majority of "common" dialysis complications are in reality iatrogenic in nature. Access complications appear to be no different.

I would hope that the story of dialysis will one day include a marvelous period of reawakening of how to do things better. The intensive care central line infection rates ravaged patients throughout America until a wise doctor in Johns Hopkins realized that we could improve the technique of inserting and caring for central lines. (here and here) Today, using a simple protocol for all of these procedures, infetions of a central line is now consider a "never" event since it should never occur. This is a prime example of improving the technique of a procedure to eliminate "common" infections which in the end analysis were iatrogenic in nature.

The dialysis industry has yet to embark on the same quest of excellence that our colleagues in other specialities have embraced decades ago. I understand that my risk of infection and complications is quite low even with daily dialysis due to adherence to strict techniques to eliminate potential complications. I am not alone in that many home hemodialysis patients have never had any major complications for years either. Is it not time to start looking at how to prevent complications instead of spending so much time and energy trying to denigrate optimal dialysis?

Perhaps I am simply asking too much but I don't believe so. With my understanding of the benefits of daily dialysis, I wonder when will the American nephrology community learn how to best apply simple techniques to routine dialysis practice that in the end is not costly at all and will save patients suffering, death and pain while reducing secondary treatment costs substantially.

Yes, daily dialysis in the hands of current technicians may indeed be dangerous. Daily dialysis in my hands is easy, safe and effective by strict protocols much in the same fashion as the central line bundle. I wish I could be there for every single patient to apply my own tried and true hygiene and cannulation techniques I have learned from many wise people such as Stuart Mott, but alas, I can't nor can Stuart. Why is it that select individuals can perform these procedures with minimal complications, yet the industry in general cannot? I believe I know the answers to that question, but the industry is not even asking that question. Perhaps that is the biggest problem of all.

Optimal Dialysis: Forty Years of Hope and Despair

By Peter Laird, MD

Shortly after the onset of hemodialysis coming to the forefront as a viable life saving procedure in the 1960's, researchers hypothesized that daily dialysis would be the optimal treatment modality for artificial renal replacement therapy. Later, Dr. Carl Kjellstrand provided the theoretical physiologic justification for more frequent and longer duration hemodialysis with the "Unphysiology Hypothesis" in 1975. 

The Rationale for More Frequent Hemodialysis – ‘Unphysiology’ 

In the early 1970s, Kjellstrand et al. [12, 13] investigated factors related the untoward effects of dialysis. They showed that large fluctuations in body weight, electrolytes, osmolality, and urea concentration were more important with respect to morbidity than concentrations of small uremic toxins or middle molecules. This led them to formulate the ‘unphysiology’ hypothesis which suggested that wide swings of solutes and fluids in the body were significant causes of morbidity in dialysis patients. Daily or continuous dialysis would more closely mimic the function of the native kidney by reducing the magnitude of solute and fluid oscillations and so would be expected to be superior to the usual intermittent dialysis regimens.

Interestingly, despite the long standing skepticism of quotidian dialysis protocols by the American nephrology community, researchers developing new dialysis technology such as the implantable artificial kidney, Victor Gura's WAK and other renal replacement devices in development all are in agreement with Dr. Kjellstrand's Unphysiology theory of more frequent and longer duration therapies. (here) Interestingly, even Wikipedia understands the underlying physiologic basis for developing these new renal replacement devices:

Need for a bioartificial kidney

Over 300,000 Americans are dependent on hemodialysis as treatment for renal failure, but according to data from the 2005 USRDS 452,000 Americans have end-stage renal disease (ESRD).^[2] Intriguing investigations from groups in London, Ontario and Toronto, Ontario have suggested that dialysis treatments lasting two to three times as long as, and delivered more frequently than, conventional thrice weekly treatments may be associated with improved clinical outcomes^[3] Implementing six-times weekly, all-night dialysis would overwhelm existing resources in most countries. This, as well as scarcity of donor organs for kidney transplantation has prompted research in developing alternative therapies, including the development of a wearable or implantable device.^[4]

The fiscal reality of lack of available resources to implement universal access to quotidian dialysis has in my opinion greatly influenced not only government policy on hemodialysis funding and modality in the United States (here), I believe it has also over shadowed and influenced research on quotidian dialysis as well. Anyone that attends the Annual Dialysis Conference expects the lively debates between nephrologists who passionately support more frequent and daily hemodialysis as opposed to those who equally voice opposition to quotidian dialysis.

The Frequent Hemodialysis Network study group findings on short daily hemodialysis and nocturnal dialysis dialysis demonstrates this paradox clearly. The short daily hemodialysis arm of the FHN study showed positive outcomes for daily dialysis but it appears that only the negative findings of the nocturnal arm matter to the nephrology community despite the excellent methodology of the FHN short arm vs. the deficiencies of the FHN nocturnal arm. (here and here) 

In March of this year, the nephrology community will gather once again at the Annual Dialysis Conference and debate the efficacy of more frequent hemodialysis vs conventional in-center treatment. An important part of those debates will involve the nocturnal FHN study:

Debate: More Frequent HD should be Recommended to Thrice Weekly HD Patients

• 8:00
  There Is Enough Evidence to Support this Recommendation - Madhukar Misra, MD
• 8:10
  The Frequent Nocturnal Hemodialysis Randomized Controlled Trial Does Not Support this Recommendation
  Alan Kliger, MD

Dr. Kliger will apparently sing a different tune speaking against more frequent HD than he did when he was appointed to the NxStage scientific advisory panel in 2011:

NxStage appoints Alan Kliger, MD to scientific advisory board

"The improved outcomes we saw in the FHN randomized controlled trial of daily dialysis should encourage patients and their physicians to consider daily hemodialysis as a serious option," said Kliger. "I''m excited to be involved with the team at NxStage, which is pioneering daily home dialysis with the System One in the U.S. and internationally."

More frequent hemodialysis is the hope of many patients today facing ESRD, but all too many nephrologists oppose the application of this simple therapy to their patients based largely on poor reimbursement from CMS. The despair of patients subjected to conventional in-center hemodialysis is evident with every single treatment where patients suffer from intradialytic hypotension followed by cramps, vomiting and passing out in centers that maximize profits at the expense of patient's outcomes. For over forty years we could have done better here in the United States and saved countless lives and further spared pain and suffering of patients yet we did not.

It is time for nephrologists to evaluate dialysis studies with a more rigourous eye towards poorly enacted methodology leading to questionable results. The FHN Nocturnal study is in my opinion a shameful publication that is fraught with such botched execution of its protocols that no one should uphold this as a reason to not engage more patients in daily dialysis. It is time to publicly admit the failure of the FHN nocturnal arm and declare this study null and void. Instead, just as nephrology dismissed the "insignificant" results of TIME in the NDCS (here) in 1981 leading to short dialysis duration and patient suffering and death, the FHN nocturnal study has the potential of setting daily dialysis to the back burner once again.

The NCDS dominated the optimal dialysis debate for decades until those that know and understand the power of more frequent and longer duration dialysis could produce the studies needed to bring the NCDS results into question. How many decades will the FHN nocturnal study dominate the debate on quotidian dialysis? Hopefully it won't given how flawed it is. However, the unjustifiable bias against daily dialysis continues today perhaps even more determined than it was before the short daily dialysis FHN study showed positive outcomes  for more frequent dialysis. Observing this highly respected researcher using the FHN nocturnal study as a basis for opposing more frequent dialysis sadly leads me to despair the number of people who will not have access to the benefits of daily dialysis because of this. 

The government support of research for new renal replacement therapy based on Dr. Kjellstrands "Unphysiology" theory is a source of hope but their hypocritical opposition to daily dialysis serves only to further despair. Dr. Kjellstrand was correct in 1975 and he remains correct today that more frequent and longer duration dialysis is the optimal dialysis strategy. Perhaps our only hope will be when these new technologies prove as cost effective as renal transplant. In that scenario, those that now vigorously oppose daily dialysis will likely become some of their most passionate supporters. We are left only with hope since it seems those that could make a difference today remain blind to our despair.

CMS and Home Hemodialysis: The Story of 40 Years of Neglect

By Peter Laird, MD

The 1973 ESRD Program began with an aura of hope and expectation of ending the suffering of countless renal patients ravaged by a disease that had only recently been a certain death sentence by slow and protracted suffering.  The "nobel experiment" which came to life by the serendipitous invention of a simple shunt became a Federally funded entitlement program literally by the stroke of a pen.

End Stage Renal Disease Program

In 1972 the United States Congress passed legislation authorizing the End Stage Renal Disease Program (ESRD) under Medicare. Section 299I of Public Law 92-603, passed on October 30, 1972, extended Medicare coverage to Americans if they had stage five chronic kidney disease (CKD) and were otherwise qualified under Medicare's work history requirements. The program's launch was July 1, 1973. 

At the start of the ESRD Program, the National Dialysis Registry data shows that on January 1, 1972 40.2% (2,001) of 4,981 patients were on home dialysis - HHD + PD - there were only 25 PD patients at home. 

On January 1, 1974 the figure was 33.0% (3,402) of 10,306 patients  were on home dialysis including 59 PD patients at home.

The politics of home hemodialysis then sadly began in earnest. The pioneers of dialysis developed home treatments to augment the few available hospital based dialysis machines to expand the number of patients that they could treat effectively. Home hemodialysis treatments were significantly cheaper than the in-center treatments by nearly a third in the early days of the ESRD program. 

NBC Commentator Dr. Arthur Caplan Calls Dialysis Cruel and Lousy Care

Data supplied by Richard Rettig,(page 3) a Rand Corporation scholar, shows that in 1972, in-center dialysis costs were between $27,600 - $30,500 while at the same time home dialysis costs were only $14,900 for the first year of therapy and only $7000 for each year there after.

The true tipping point between acceptance of home hemodialysis vs. in-center treatments came in the 1978 congressional hearings prompted by escalating costs of the ESRD Program. At that time, Edmund G. Lowrie, Vice President of National Medical Care, Inc., promoted a false understanding of the costs and effectiveness of home hemodialysis that Dr. Chris Blagg was unable to overcome in his testimony which fell on the deaf ears of those who refused to hear the true story.

The politics of health cost containment: end-stage renal disease

R.A. Rettig (pages 132-133)

Dr. Edmund Lowrie of Peter Brent Brigham Hospital attacked the Seattle experience directly on two points: "our analysis indicates that the cost of self-care dialysis is not significatly less than limited care dialysis, and that the the indiscriminate use of home dialysis may lead to unacceptable patient mortality." . . . "After careful analysis," Lowrie claimed, "the only obvious reason for this inferior patient survival that we can think of is the indiscriminate use of home dialysis therapy." Lowrie's testimony created the impression that three-year survival of home patients in Seattle was unacceptably low. But as Blagg later pointed out, the 58% applied to all Seattle patients, center and home, and inclued elderly and diabetics insignificant numbers."When we look at patient survival on home dialysis," Blagg wrote, "and exlude the center dialysis patients, the 3-year survival in our program is 74 percent including diabetics; if we exlude diabetics, the 3-year survival rate in pateints aged 55 of less is 81 percent on home dialysis. . .

But the political damage had been done. 

Today, after nearly forty years of neglect, home hemodialysis is only a shadow of its humble beginnings mainly due to adverse funding ratios from the hands of congress and CMS. Despite an abundance of evidence of its cost effectiveness, despite widespread acceptance in the rest of the developed world, home hemodialysis remains underutilized and underfunded today despite promises to the contrary.

NxStage internal data presented to CMS in recent public comments on the Renal Bundle and the QIP reveals significant discrepencies between reimbursement for peritoneal dialysis vs. home hemodialysis despite significantly longer training requirements for home hemodialysis (HHD) and and higher associated training costs. Total hours training, PD  - 32, HHD - 103. Reimbursement: PD $1,238, HHD - $408. Estimated HHD costs in a 2007 NxStage survey showed the burden of training for one HHD  patient was at least $4000.

The lack of adequate compensation for necessary training presents an undue disincentive to further acceptance of HHD as the modality of choice for selected patients. According to the same NxStage public comments, only 24% of current dialysis centers are certified for HHD and even fewer enroll patients into their programs despite extensive clinical data of improved outcomes with HHD. Adding to the financial disincentives, few nephrologists or units ever counsel patients on the benefits of home hemodialysis with as few as 12% of patients receiving informed consent on this underutilized modality. (here) Further studies reveal increased requests for home hemodialysis when patients are informed of this option showing the effectiveness of patient education on HHD. (here)

Despite substantial benefit, reduced long-term costs, and proven efficacy of informed consent for HHD, CMS continues to neglect this much unfairly maligned therapy. For those fortunate enough to participate in home hemodialysis training and treatment, the benefits are immediate and longstanding as noted by frequent testimonies on various dialysis advocacy web pages. Only congress and CMS fully appreciate their own reasons for why the continue to withhold appropriate funding of HHD after nearly forty years.

This puzzling story continues to defy any reason and logic. Perhaps one day, enough dialysis patients will know and understand why it should often be their first choice and a shout will go forth that no one can ignore any longer at CMS. But until that day, the voice of despair and discontent with conventional in-center hemodialysis will apparently continue to fall on deaf ears. Perhaps one day, we can only hope that someone, somewhere  and at some time one who can make a difference inside our government will.

The Dialysis Dilemma: What Would Scrib Do?

By Peter Laird, MD

Despite the demonstrable progress in recent years delivering the message of optimal dialysis, from time to time, a very negative portrayal of dialysis emerges in the popular press that paints a shaded picture of the true miracle of hemodialysis that today sustains two to three million people around the world.

I was quite disappointed to read  a recent article that ended on just such a sour note of despair with dialysis despite celebrating the stories of both Bill Peckham and Nancy Spaeth who have graced the world with lives well lived despite ESRD. After all, both Bill and Nancy are still working and contributing greatly to their families, friends and community. It appears that the author of this article failed to capture the true miracle of saved lives with hemodialysis with their example she noted, but does not appear to truly understand.

The dialysis dilemma: urgent need vs. overtaxed system

A HALF CENTURY ago, nobody predicted so many people would have end-stage kidney disease. Or that treating it, per patient, would be one of government's most expensive entitlements.

Now, nephrologist Kelly says, the problem isn't picking which patients should get dialysis; it's that doctors, patients and families seem unable to pick which patients shouldn't.

A few months ago, at a NKC celebration, he called for reconstituting "The Committee" — albeit with a 180-degree change in its mission. It was a moment to pause.

Kelly fervently believes that health care is a right. But he also thinks dialysis has gone too far.

Unfortunately, the story of dialysis today is not that it has gone too far, but that it has not gone far enough. Hemodialysis machines operate in much the same fashion as they did when the doors to renal replacement therapy swung open with the ESRD program in 1973. Since that time, despite the technological revolution that we have seen throughout modern medicine with improved survival from technological advance, the basic components of hemodialysis remain remarkably the same. Although even here there are indeed improvements in buffers, hollow fiber tubing, software, and other aspects of delivering the provision of dialysis, one aspect that has not seen any improvement in hemodialysis is improved outcomes.

The for-profit dominated dialysis industry has focussed their efforts on improving the bottom line of corporate profits but as an industry they have not advanced the technology to improve outcomes in any sensible fashion. In this regard, dialysis has not gone too far at all. Nevertheless, Dr. Kelly is speaking of the ethical dilemmas of open access to this expensive care and not the need for further technological advances.

The dialysis dilemma: urgent need vs. overtaxed system

 Today, with the door to dialysis swung wide open, Kelly argues, doctors, families and patients need a committee because someone, somehow, has to say no.

He battles with himself out loud. "I think, 'Am I some kinda Hitlerian guy, that I want to stop all these treatments?' "

Then he recalls "Scrib," Scribner himself, fearlessly insisting that uncomfortable, tough issues be aired. "I frequently say, when I'm dealing with a case, 'What would Scrib do?' " Kelly says.

"I'm trying to do the right thing — what I think is the right thing."

The study of medical ethics can be summed up simply enough as doing the right thing in difficult circumstances. I am pleased that Dr. Kelly seeks the wisdom and knowledge that "Scrib" would advise America in these trying times. However, seeking to return to "God committees" more properly called death panels from his description is not the avenue that I believe Scrib would venture with the so called "dialysis dilemma" we face today.  Dr. Christopher Blagg wrote a touching and informative tribute to his lifelong friend and colleague shortly after Dr. Scibner's untimely death in 2003. One short paragraph in this tribute speaks loudly on where I believe Scrib would want us to go:

Belding Hibbbard Scribner - Better Known as Scrib

Scrib always said he had been lucky all his life, but he was successful because of his perseverance in problem solving and his delight in tinkering with devices. He was a great teacher and leader and a generous person. His first concern was always for patients, and his other major concerns included for-profit dialysis, the future of U.S. medicine, and the future of the world.

I believe Dr. Blagg characterized best "what would Scrib do?" by noting his devotion to patients first and foremost coupled with his ability for problem solving. The great tragedy of dialysis is not that we have too many patients in need of this life saving technology,  but instead that we have spent too little time problem solving and tinkering with  any new technology. Modern technology seems to have side-stepped the dialysis industry as it ground the constant drumbeat of profiteering above and beyond the love of the patients they serve truly giving a new definition to blood money.

What would Scrib do? I believe he would tinker and problem solve with newer and improved technology and freely give that technology to medicine for no profit of his own as he did with the Scribner Shunt. Instead of profiting millions of dollars personally by his new invention, Dr. Scribner freely gave this life saving device to the entire medical community which is an ethic sadly missing today.

I don't believe that Nancy Spaeth and Bill Peckham wish to be known for an article essentially calling for death panels in the current world of re-engineering dialysis. Instead, they are filled with courage and devotion to this modern medical miracle made possible by a humble man. Where is our present day teacher and leader who shall advance the provision of dialysis in the same spirit of saving lives as both Bill and Nancy testify daily? Both knew and loved Dr. Scribner who served not only as a mentor, encourager and teacher, but as their lifelong friend. Dr. Scribner did not heed the modern admonition of doctors not getting attached to their patients, he instead embraced them with all of his heart and mind and soul.

How many nephrologists today have patients that will outlive them? Even Dr. Scribner's very first patient, Clyde Shields,  lived for over eleven years before cardiovascular disease claimed his rejuvinated life. The amazing panel of Dr. Scribner's patients have lived lives testifying of this truly remarkable invention. (here, and here)

I believe he would approach all patients with severe renal impairment with a courageous strength to save lives above all other concerns. Has dialysis gone too far? No, not at all. It has instead failed to advance far enough that the provision of dialysis is still far too excessively expensive and strangled by an industry that cares first and foremost about reaping ever enlarging corporate profits. What would Scrib do? I believe Dr. Blagg told us quite clearly in his loving tribute that he would focus on the patient tinkering with new technology and giving it all freely away to save lives. Yes, that is what Scribner would not only do, but that is what he did. 

Home Hemodialysis Competency is Lacking in American Nephrology Training Programs

By Peter Laird, MD

Home hemodialysis was at the forefront of bringing into account hemodialysis modality as an accepted medical procedure in the early 1960's. The financial constraints of chronic hemodialysis especially in-center were beyond the resources of most institutions shortly after Belding Scribner, MD revolutionized the treatment of chronic renal failure with the "Scribner" Shunt. By the time that the 1973 ESRD program provided financial relief for all eligible US patients with renal failure, nearly half of the patients treated at that time dialyzed in the comfort of the their own home. Sadly, far too many new nephrology graduates have forgotten these lessons from the history of dialysis.

In a recent CJASN publication written by Jeffrey Berns, MD, the editor of the Medscape nephrology news section, notes that 65% of recent nephrology graduates lacked competent training in managing home hemodialysis patients. Only 15% of these fellows surveyed felt competent to manage home hemodialysis pateints:

A Survey-Based Evaluation of Self-Perceived Competency after Nephrology Fellowship Training

Areas in which more than 25% of fellows during their second or later year of training answered “No” included cystic kidney diseases (50.1%), plasmapheresis (60.1%), renal US (51.8%), PD (36.5%), home HD (65.0%), arte- riovenous access management (34.4%), nephrolithiasis (34.7%), geriatrics (25.2%), and palliative care (37.4.%) (M. Rosner, personal communication). Thus, several of the areas cited by respondents to the survey reported here as not providing adequate training were similarly cited by fellows still in training, emphasizing the need to address these areas of training.

I had an  interesting encounter with an expert in transplant nephrology when I had an iron infusion at Kaiser Sunset in Los Angeles last year. While rounding  during the hemodialysis session, I asked him if he was familiar with Pauly's study on nocturnal hemodialysis outcomes vs. transplant finding comparable outcomes in mortality. (here) This nephrologist who had just completed a prestigious transplant nephrology training program at Cedar-Sinai and was able to advocate credibly for transplantation but he was not able to discern how daily nocturnal dialysis faired against his preferred renal replacement modality. If a transplant nephrologist from such a well respected institution cannot truly give informed consent on transplant vs nocturnal hemodialsyis even as a bridge to transplant, how then shall we expect the average training program to rise to a level of proficiency in home hemodialysis modalities?

The true repository of home hemodialysis knowledge is not found in the majority of nephrology programs in this nation but it instead resides within the collective patient advocacy sites and foreign nephrology programs much more so than the average nephrology program in the United States.  Dr. John Agar has long advocated for home hemodialysis utilization as a first choice for the majority of patients new to dialysis. Many patients in Australian nephrology practices dialyze in the comfort of their homes and have much better outcomes than those in conventional in-center treatment centers.

The fact that most American nephrologists are ignorant of the history of dialysis nor do they have a concerted interest in this modality does not bode well for the future of improving American dialysis outcomes.  The grave of Belding Scribner who freely gave of his invention to save lives haunts the halls of all of these nephrology programs that find it incredulous that the majority of patients dialyzed at home in the 1960's with primitive equipment by today's standards.

The truth remains that there is a major generational gap between the pioneers of dialysis and the current graduates who view dialysis as a futile and unworthy treatment option for the majority of patients when in fact if employed in a quotidian fashion with increased frequency and duration can and does offer a return of useful life.

Perhaps some day, Scribner's dream of an informed and enthusiastic acceptance of this "noble experiment" will come to pass in America despite the fact that one of the greatest medical technologies remains in the hands of a profession truly unworthy of how well they could but don't use this modern medical miracle. Perhaps someday, restoration of whole individuals will be commonplace instead of the unusal oddity when it comes to dialysis.  That day is one nephrology progam at a time away from acceptance even in the best institutions. Perhaps someday. We can only hope.

 

Are American Nephrologists Dialysis Money Sucking Leaches?

By Peter Laird, MD

In a recent post on HemoDoc, (here) I evaluated calls by some in nephrology to increase payment for their services. There is no doubt that many American physicians truly earn their pay and I have no doubt that my colleagues in nephrology do likewise work hard. However, at least one person took exception to my essay and categorically stated that nephrologists are not "dialysis money sucking leaches." However, the unfortunate historical record of American dialysis care does not corroborate that statement. (here)

While we can look to multifactorial improvement in cardiovascular outcomes not simply from revascularization alone as correctly pointed out in the above comment, but instead by a combination of advances in the pharmacologic interventions of myocardial infarction and improvements in revascularization techniques as well which I duly noted in my post; sadly I cannot state the same about dialysis outcomes in the US.

The point of comparison is the measurable advances we see in the treatment of cardiovascular disease in the general population vs. the stagnation of dialysis outcomes in the United States in particular.  When I see the median longevity on dialysis of 36-38 months, (here) which has not improved substantially for decades despite a concerted effort by many to promote optimal dialysis techniques, I must question the American nephrologist individually and collectively who are the only doctors legally able to prescribe dialysis treatments.

Indeed, what technological advances can we point to in the standard in-center treatment of the majority of American dialysis patients that has relieved pain and suffering of our patients in as dramatic a fashion as in many other areas of medicine?

As a dialysis patient myself, I do not take lightly the denial of individualized care I have seen in many units personally. I have been subject to cattle call dialysis sessions where I was yelled at for coming 25 minutes early instead of 30 minutes and suffered inadequate clearances simply because that unit refused my standard treatment at my home center. (here) To deny the existence of money sucking leaches in the field of nephrology is to remain in denial of the truth of the for-profit dialysis industry of the last 40 years.

Clinics Pad Kidney Dialysis Costs

By Jack Anderson

"Washington - Of all the corporate Scrooges in the world, none is lower than one that would squeeze profits form the sick and debilitated."

Today, the American nephrologist cannot stand up and proclaim significant improvements in the treatment of ESRD in the same manner that you can for a broad segment of other high tech specialties. 2012 was supposed to be a year when we saw new dialysis technologies approved by the FDA but 2012 has come and gone and we are not doing any better today than we did in 2011.

I could easily have cited improvements in the treatment of childhood leukemia or peptic ulcer disease or a myriad of other conditions but only used improvements in cardiovascular outcomes as one ready example. Focusing on my one example renders no justice at all to the deficiencies of dialysis care in America that lie entombed in stagnation and an intransigent resolution to not change the system whatsoever. In the meantime, patients on hemodialysis in America have a worse prognosis than AIDS patients and many cancer patients. Shall we gain any benefit by criticizing those who stand up and ask simply why cannot we do better today than we did yesterday?

This remains a uniquely American debate since the rest of the developed world has long since embraced the basic tenants of optimal dialysis. America remains paralyzed by an industry that is one of the most profitable in the US, (here) that is unless you are one of the unfortunate patients beginning dialysis today that only has 36-38 months of median life expectancy remaining. I believe that the American nephrologists have much that they need to account. We could do better and we should do better but shall we do better is the unanswered question.  There remain many champions of dialysis improvement in America, but sadly in my own venture as a dialysis patient, they appear to be few in number collectively. What then do we call the many American nephrologists who do not advocate for documented improvements in basic dialysis outcomes in America?

The DaVita Difference: The Billing King

By Peter Laird, MD

Each month, Kaiser sends an explanation of benefits for my dialysis services. I see my dialysis team once a month, I do all of my inventory ordering, I perform all of my own medical treatments and I draw my own labs. My wife often wonders why she doesn't get paid to be my assistant since "we do all of the work." Her question is even more pointed when we saw the bill to Kaiser for August 2012 in the amount of $72,490.40.

In Australia and other nations, patients are given financial incentives to perform dialysis at home since it saves the health system tens of thousands of dollars every year. I am sure that is a non-starter politically here in America, but where can a dialysis provider supervising home hemodialysis patients only on a monthly basis have the audacity to generate such an outrageous bill? Indeed, my entire annual cost of dialysis and related medical costs is well below $72,000 each year.

At the same time, DaVita denies me enough supplies to last that one month period with one box of masks, 50 in each, which is less than needed for both my wife and I. One box of alcohol pads likewise fails to cover my monthly needs.  They further provide my dialysis needles on a one month basis compromising their integrity since they are not shipped in their original packaging of a box of 100. Did they use gloves and wash their hands before they placed them in a cardboard box not intended for this purpose and then shipped it to me through the mail system? Does this compromise my clean supply table every day as I attend my dialysis set up diligently in accordance to rules of sanitation?

Needless to say, Kaiser does not pay that bill in entirety due to contractual agreement. Yet for some health care providers, they do not have the ability to deny all of these claims which would total over $800,000.00 for a year of home hemodialysis treatment. With Kent Thiry publicly stating in a recent presentation that the business of DaVita is not about the patients, their greed and profiteering is evident each and every month when I obtain my explanation of benefits.

I understand that it is not about the patient each and every day that I fax my daily dialysis flow sheet so that the nurses at my unit can enter it into the DaVita billing system. Yes, DaVita is the king of dialysis billing. My impression of their entire system is that it is geared to billing much more so than to patient care. After all, Kent is right, it is not about the patient. That is the DaVita difference.