Is the Dialysis Industry the Enemy?

By Peter Laird, MD

Fix Dialysis is hosting a large internet discussion on ways to fix the current problems of the American dialysis industry.  Several people have called for essentially a peace treaty with the dialysis industry unilaterally by dialysis advocates, not in such words, but that is the underlying message. There is a call to work with the dialysis industry in a joint effort to bring about better patient outcomes.  I know of no one that would disagree with that goal if possible to accomplish.  However, there are obstacles to overcome if dialysis advocates are to adopt this approach, not the least of which is the American  dialysis industry itself.

I would like to make a quick comment about the so called "anti-industry" voices as some have coined. As a physician with fiduciary responsibilities to my patients for many years, their outcomes were my responsibility to improve to the best of my abilities. Yet, the dialysis industry in my opinion has for decades flaunted this basic duty common to all health care providers and in many ways still does.

I am quite interested personally in the market forces in the home hemodialysis segment especially that in many ways will be our biggest ally.  If the CMS bundle actually introduces real incentives  for these improved outcomes and the competition for the home dialysis market leads to more patient demand, then we may have begun a new era in the very unique American dialysis story. Yet, on the other hand, we still have practices by the American dialysis industry that do not lead to best clincal outcomes for their patients today in complete opposition to the fiduciary duties they are responsible for.

For instance, reuse of artificial kidneys was necessary to allow the antiquated equipment to best serve the patients at the beginning of the industry and to avoid the first use syndrome related to ethylene oxide which is no longer used since we now have gamma irradiation and other methods for sterilization. Yet, a high percentage of the American dialysis industry continues to reuse artificial kidneys for purely profit driven motives. Many nations have long since abandoned this practice. Reuse adverse events make headline news all too frequently from lack of proper rinsing of the chemicals to giving patients the wrong kidney from another patient exposing them to Hepatitis C and many other transmissible agents.. Since it is impossible to eliminate all human error in any endeavor, it is time to put an end to reuse that the industry could unilaterally accomplish under their fiduciary duties alone to first do no harm.

We now have dozens of articles showing high ultrafiltration rates having adverse and deadly effects, yet I know of no dialysis industry leader that has policies to reduce this clinical practice. If they exist, I would be more than happy to publish them on my website with a positive commentary attached.

The over prescription of EPO for pure profit may have contributed to the deaths of untold patients, yet it was CMS through the MIPPA and the Bundle that will turn this into a negative cost center for the industry. That is only now going into effect this month.

The lack of informed consent by the dialysis industry is a national shame well documented.

The lack of attention to decades of improved outcome studies by increased frequency and duration of dialysis, and now no movement that I have seen to date to implement the results of the FHN into daily dialysis practice.  Perhaps the movement towards home dialysis could be construed as that very response, but 4000 out of 380,000 patients on home hemodialysis is less than a lackluster response in my opinion.

I will forgo other examples for the moment, but the reality of the situation is if the dialysis industry wishes us NOT to consider them our enemy as dialysis advocates, then they will have to earn that trust in my opinion. To date, I have not witnessed an altruistic movement on the dialysis industry to assure us that the years of abuse of the American system has ended and that we are now in a new era. If the dialysis industry should reach out and wish to work with us, then I will be the first to join with them in applause and support.  I am told to look past their past, yet it is indeed the current situation that is still concerning to me.

Until that time, as a board certified internal medicine specialist, I consider the medical knowledge that I possess of errors in clinical practice perpetuated by the industry today as a matter of business and profit making which I shall continue to speak out on these issues. It is not that I in any way refuse to "work" with the dialysis industry, they simply have not in any sense invited me to do so and I do not expect that invitation to come any time soon. When and if they do, I will be the first to tell all that I am now working together with the American dialysis industry for the common good of all dialysis patients in America.

Just my own opinion and my own thoughts on calling for a peace treaty among dialysis advocates and the American dialysis industry.

Comments

[MooseMom]

Could you name five things that the dialysis industry could do right now that would have them gain your trust?

[Peter Laird, MD]

Trust is something that is earned. I will leave it to the dialysis industry themselves to define such an outcome if that is something that they desire.

[MooseMom]

Come on, help me out here. There are so many issues, so many obstacles, so many players that a newcomer like me needs to find a starting point. I know that trust is something that is earned, but we can't wait around for the dialysis industry to start singing kumbayah. So, if this was an ideal world and the dialysis industry was eager to gain your trust, what are five things they could do to achieve that goal?

[Peter Laird, MD]

Dear MooseMom, not to skirt the issues, but limiting the changes needed to only 5 would artificial limit the discussion, there are unfortunately more than 5 uniquely American Dialysis practices that in my opinion are contributing to poor outcomes for the sake of monetary gain just as Dr. Scribner stated many times over.

To sum them all up, I woud have to address your question with a simple retort, when the dialysis industry will provide their patients the same treatment parameters and modaliites that they themselves would choose if faced with ESRD, we will have arrived.

[roberta mikles]

Oh Peter, you hit a spot in our lives here, in my home.. When my father and I brought forth concerns to the medical director of his unit e.g. infection control, or lack of.... etc. we were told, especially me -- that I did not trust staff and that we were looking for fault with implying lawsuit..............We were told 'you need to trust staff (and, physician)..but what many did not understand,, is that trust is earned and if staff are not implementing correct practices then one can not trust... Earning trust... interesting concept..If a patient and/or family member is educated to what should be and they observe such not being done... well, how can you trust. There were many staff who did the right thing... and, even six years later, those who were not doing the right thing continue..
What was disappointing was to hear, over and over, about the unit not having infections and rates being so great... then to learn that in 2008 the facility was double that of state and national averages/percentages for access-related infections. Well, I was not surprised considering what I observed e.g. preparation for cannulation. I observed staff touch the outside of a contaminated treatment cart, opening a drawer, then taking the 2x2s for cannulation procedure, without washing their hands. Indeed, these gauze pads are not sterile but clean...but to touch a grossly contaminated object then those nasty germs are on the gauze that is touching the access site.... that was just one of many observations. I could go on and on, but to learn of the double rate, I knew we were doing the right thing in reminding staff (some, not all). But it does make a patient anxious and does not do anything to support a good relationship with staff because for the most part staff resent being reminded.. and, between the years of 2006 and 2008 35-50% of deaths were contributable to infection. So, I guess again, when we reminded staff, some every treatment, we were not too far off base. Thank God my father was educated and able to remind staff, otherwise, I know he would have acquired an infection. Interesting, one simple aspect was that no one disinfected chairs per the facility policy... interesting... but as I read the survey, latest one, they were cited. I never, in six years, ever saw anyone disinfect according to policy - which I learned as I read the survey. Ironic that the facility had their recertification survey the same day my father died (at home). The facility was inspected in the end of 2006 and then half way through 2010 .. Three and a half years.. or a bit less. This is infrequent, but the prior survey, as I read it, I was shocked to see over four deaths in center within short time span. Interesting that all deaths, maybe five, were all reviewed by the medical director and found to not be the result of preventable error. Well, ... interesting that after that survey, one staff came to me with questions e.g. what would happen if someone made a mistake, etc.At that time, I had not read the survey, as it was in process. But, again, there are good and bad in all facilities and those that care and those that don't. I am not stating that these deaths were result of preventable errors, just stating what I know and my opinions. Surveys have a voice of their own. There is NOT any reason why a patient should have to be concerned about reminding staff to implement a correct practice be it infection control, or machine settings. And, often, medical directors have no clue what goes on when they are not there, in addition to the dysfunctional cohesiveness that exists in many units....
opinions by Roberta Mikles RN
www.qualitysafepatientcare.com