By Peter Laird MD,
The influences of two cities in America during the last fifty years is the tale of two cities taking the technology of dialysis in two different directions. Truly, "It was the best of times, it was the worst of times..." Dr. Scribner in Seattle started the entire field of chronic hemodialysis by his inspiration in the middle of the night for the Scribner Shunt.
Belding Scribner: The Inventor of Shunt Dialysis
Scribner came upon his idea in 1960 after he saw a young man recover briefly following dialysis, only to die a few weeks later. At the time, haemodialysis could only be performed for a few cycles. In a painful procedure, glass tubes were inserted into a patient’s blood vessels, permanently destroying them for further access.
The patient weighed on Scribner’s mind until one night when he suddenly awoke with an idea of how to save patients with end stage kidney disease. He would fashion a loop between an artery and vein, allowing the device—rather than the patient’s own vessels—to be opened and closed with each cycle of dialysis. that it was just like turning on the light from the darkness.”
Dr. Scribner, a patient in his own right from chronic eye problems, immediately freely gave his invention to the medical world for one sole purpose, to save lives, profiteering never entered his mind. This gift followed the example of Wilhelm Kolff, the inventor of the first workable dialysis machine who freely gave his invention to the medical world to save lives as well.
Kolff’s machine is considered the first modern drum dialyzer, and it remained the standard for the next decade. At the time of its creation, Kolff’s goal was to help kidneys recover. The brave doctor had no way of knowing that his invention was one of the foremost life-saving developments in the history of modern medicine.
After World War II ended, Kolff donated the five artificial kidneys he’d made to hospitals around the world, including Mt. Sinai Hospital in New York. Because of this unselfish act, doctors in many countries were able to learn about the practice of dialysis.
Wilhelm Kolff gave the blueprints of his machines to Dr. Thorn at Peter Bent Brigham Hospital in Boston. They shipped 22 of these machines updated at Brigham hospital around the world between 1954 and 1962. Yet, it was not until Dr. Scribner invented his shunt that chronic hemodialysis beyond one or two treatments became a reality. Dr. Scribner immediately set out on his most important mission, to make this new technology widely available and he was the driving force behind the 1973 Medicare legislation initiating the ESRD Medicare program. The Seattle experience brought forth the new field of bioethics and the first dialysis unit opened which still operates now as the Northwest Kidney Center in Seattle, a non-profit organization that is still a leader in dialysis innovation today.
However, in Boston, a new corporation sprang forth from among the Peter Bent Brigham Hospital doctors called National Medical Care, Inc. After two years, in 1970, it became the first for-profit dialysis company. The era of altruistic innovations gave way to the era of grand profiteering on a monumental scale. Despite its initial humble beginnings with the Kolff-Brigham machine, Boston would become the most influential center of dialysis making the goals of for-profit dialysis as the standard of care in America.
Dr. Edmund G. Lowrie, in a 1978 Medicare hearing changed the face of dialysis in America from predominantly a home based therapy given three nights a week for a total of 27 hours, into the current ultra-short hemodialysis of 3-4 hours sessions, thrice weekly.
The politics of health cost containment: end-stage renal disease
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 ofhome 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.50 "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.
The cast was set once again by Edmund Lowrie, et al after the Boston based NCDS ( NCDS: Revisited Three Decades Later) pronounced Kt/V as the best measure of dialysis "adequacy" and for the next thirty years, outcomes in America plummeted to the lowest of all developed nations while at the same time, the predominantly home based American therapy given to us from the Seattle model of care passed over to the Boston model of care in for-profit centers giving short, thrice weekly treatments. At the time of the hearings in 1978 on the future of dialysis in America, where the best model we know today of home based, long nocturnal therapies, fell at the hand of what we now know is the incorrect testimony by Edmund Lowrie that in-center care was better, Dr. Lowrie was a high ranking corporate officer in the for-profit dialysis chain, National Medical Care, Inc. Indeed, he later became the president of this corporation. In response to the 1995 Kurt Eichenwald NY Times article, Death and Deficiency in Kidney Treatment, the dialysis industry responded in a letter to the editor: "There is no evidence that an adequate Kt/V delivered in 2.5 hours in[sic] inferior to the same dose delivered inefficiently in 4 or 5 hours. We believe it is to everyone's advantage - patient, provider and payor - to deliver high quality dialysis efficiently at a time of limited resources."
The story of National Medical Care, Inc. in my opinion, is one of obscene profits soon after the ESRD Medicare program began paying for all dialysis care in America . Even Jack Anderson, the prototypical investigative reporter of decades past took notice of the "padding" of dialysis costs by National Medical Care, Inc: Clinics Pad Kidney Dialysis Costs.
The story of dialysis in America truly follows the tale of two cities, that of Seattle giving us chronic hemodialysis, thrice weekly overnight at home for 27 hours weekly, it gave us the first non-profit dialysis center, started the field of bioethics, and has continuously fought against those that have instead turned dialysis into one of the most outlandish profiteering medical schemes in history. Boston, on the other hand ultimately gave us National Medical Care, Inc., the NCDS and those that reduced a life saving technology done best at home into one, in my opinion, of death, despair and disability that we now own today as our American legacy of dialysis for the simple reason, in my opinion, of turning the highest profits. Improving dialysis care in America today can best be accomplished by simply turning time back to the Seattle model of care.
The Boston experiment of dialysis care in America is a failed trial of medical care at best founded on the for-profit industry standards. We can do better here in America, and it is my hope that we shall.
OK. So, what do we do TODAY and TOMORROW to change tack? I don't know when exactly I will be starting dialysis, but when it comes time, what can I, MooseMom, do to change the status quo? Tell me where to begin, and I'll begin.
Posted by: MooseMom | Monday, December 27, 2010 at 04:25 PM
Dear MoosMom,
The first place to start is as you have already done, learning about the different dialysis options. I would think that the second task would be to find which centers offer home dialysis or nocturnal in-center options and see if they are available in your health plan. If so, seek a second opinion by the nephrologist at that center and begin to plan with a cooperative health team your dialysis strategy. Since nephrologists are the only doctors that prescribe dialysis treatments, you must work through the system with them. Finding the right nephrologist and health care team is not often easy, but they do exist here in America. Home Dialysis Central has information on which dialysis centers offer these alternative treatments.
Posted by: Peter Laird, MD | Monday, December 27, 2010 at 07:27 PM
Another example would be Les Babb who in an astounding example of rising to a challenge invented the proportioning system that became the standard in dialysate delivery. He tells the story in this oral history:
I wrote up an invention disclosure and took it up to the business manager, Ernie Conrad, who was a good friend. In those days one could go from A to B without going through a mountain of bureaucracy. I said, “Ernie, I think we have something here that might generate millions if not billions of dollars. Do you think we ought to patent it?” And he sort of patted me on the head and said, “No. We’re an institution of higher education and in no way interested in commercialization. It’s university policy that if anyone asks for drawings or anything, we give them to them.”
A lot of people made a lot of money when medical ethics were replaced by business ethics.
Posted by: Bill Peckham | Monday, December 27, 2010 at 09:22 PM
Bill, thank you for the link to Les Babbs. It was once a matter of professional integrity to distribute widely any new information to colleagues on how to improve outcomes. I find it maddening today to pay up to $35.00 for studies that are 30 years old as is the case often. It was a different era and we now suffer greatly at the hands of the business model of medical care.
Thank you also for the links that made the basis of this article that you sent to me a few weeks ago, without such I would not have been able to place this post today.
Posted by: Peter Laird, MD | Monday, December 27, 2010 at 10:15 PM
Those Rettig reports were are real eye openers. There has been a whole series of them - reading them together is pretty amazing.
For profit, incenter dialysis manipulated the process each time the question of dialysis funding was at issue. They easily out gunned doctors who were naively presenting their data without spin.
Posted by: Bill Peckham | Monday, December 27, 2010 at 10:38 PM
Thanks Peter.It was a different world in the 1960s. In 1962 the Seattle Artifical Kidney Center was developed as the world's first out-of-hospital dialysis unit because the University of Washington Hospital would not allow Dr. Scribner further expansion for the dialysis program beyond the first 4 patients. Scrib and the King County Medical Society never thought of making their new center anything other than a community supported non-profit operation.
In similar circumstances a few years later the Brigham group developed an out-of-hospital unit that became for-profit and led to National Medical Care. When the Medicare progam began the potential profit margin was large and so dialysis flourished and led to what we see in the US today. As Dr. Scribner commented to a Congressional hearing and on 60 minutes, what began as a noble experiment degenerated into a a multi-million dollar money-making enterprise. Opposition by NMC to home hemodialysis - it was unsafe and the cost savings were exagerated - was one of the main reasons home hemodialysis withered throughout the 70s and 80s.
Posted by: Christopher Blagg | Tuesday, December 28, 2010 at 06:18 AM
Thank you all for continuing to educate me...and increase my own knowledge base. Although I am focused on incenter care, I can say that I have and will continue, even moreso, to refer those who contact me e.g. dialysis patients, or pre-dialysis patients, to home dialysis.
Thank you all,
Roberta
Posted by: roberta mikles | Wednesday, December 29, 2010 at 06:09 PM
I don't know how many of you follow the Renal Fellow Network blog, but this entry regarding the top ten neph stories of the year caught my eye as it addresses some of the issues presented by this blog.
http://renalfellow.blogspot.com/2010/12/top-nephrology-related-stories-of-2010.html
Posted by: MooseMom | Thursday, December 30, 2010 at 09:22 AM
Thanks MooseMom, yes, RFN is one of our Renal Links on this site and they likewise have placed HemoDoc on their Renal links as well. The RFN started by the late Nathan Hellman is now overseen by a group of renal fellows. The top 10 news stories for 2010 listed the ProPublica article as number 7, and the FHN as the number 5 story with bundling as the number one story in nephrology for the year. Obviously, dialysis and its connected issues are one of the most important topics of nephrology and the Renal Fellow Network has so noted this connection.
Posted by: Peter Laird, MD | Thursday, December 30, 2010 at 10:38 AM
I was fairly sure I was stating the obvious, that RFN was well known in these parts, but I thought that with the holidays, some might have missed this particular top ten list. I was particularly interested in the IDEAL trial. What I found, cynically, to be particularly glaring was that the top story in nephrology had to do with the financial side of practice, ie bundling...not optimal dialysis or some new amazing technology, but how dialysis providers will be paid. How illustrative of the mindset of dialysis in the US today.
Posted by: MooseMom | Thursday, December 30, 2010 at 11:20 AM
Dear MooseMom, unfortunately, that is exactly the issue when it comes to dialysis, patient outcomes are not at the forefront of many decisions made in the last 40 years. It has long since been all about money and profits, something Dr. Scribner spent the last 3 decades of his life fighting, quite sadly without overcoming the American dialysis profiteering. That remains our largest challenge today.
Posted by: Peter Laird, MD | Thursday, December 30, 2010 at 11:32 AM
It remains our largest healthcare challenge today...it's not confined just to dialysis.
Posted by: MooseMom | Thursday, December 30, 2010 at 01:12 PM
We should be honest and agree that Hemodialysis is about THE ALMIGHTY DOLLAR.It started out as an option to keep a patient alive until a kidney transplant occured.We have allowed companies from across the water D & F TO MAKE BILLIONS OFF OF SICK PATIENTS that we pay for..
Posted by: me.yahoo.com/a/hu57zewOivbeMNTseFyzrkoimA-- | Monday, January 10, 2011 at 10:08 AM
Hey Peter! I've been looking out for some posts from you re the conference in Phoenix (I figured you'd remove the spam..haha). I'm glad to hear that you didn't "kill the Bill" (I'm so funny, I know); I know how much you two love to talk politics! I'm really looking forward to your thoughts about the conference! Post soon!
Posted by: MooseMom | Thursday, February 24, 2011 at 02:29 PM
Thank you Moosemom, had some other pressing things in the last two weeks on top of the conference. I was only there for a day but what a day. Great conference especially the Home Dialysis conference on Saturday where the gathering of the advocates for home dialysis is at it's highest, talk about being able to preach to the choir. Bill is doing well and great to see him back in the saddle blogging again in his rightful "throne." LOL
Will try to get some posts out soon.
Take care,
Peter
Posted by: Peter Laird, MD | Friday, February 25, 2011 at 12:15 PM