HemoDoc, From Doctor to Patient

The Davita Difference: the King of EPO has no Clothes

By Peter Laird, MD

Davita made headline news in the Denver CO area recently over their business practices to include the use of higher than average EPO dosages that made their company millions of dollars. When I first started hemodialysis, even though I had a Hb level over 12, I was automatically started on EPO for a few weeks. I declined any further EPO after reviewing the medical literature on the risks and benefits of ESA use. This was back in 2007 prior to the release of the several studies which do show significant risks associated with ESA use including increased risk of MI, stroke, graft thrombosis not to speak of the increased cancer risks especially in patients with prior cancers who are now also on hemodialysis. Interestingly, my decision to stop EPO was not met with enthusiasm from my medical team. I was fortunate that within only a matter of weeks after stopping EPO, reports of adverse effects of this "wonder" drug stopped those criticisms of my decision short.

It turns out that my choice was prophetic. Nevertheless, despite several recent studies, the issues of increased cardiovascular events had already been duly noted even in the PDR prior to 2007 when the first of several reports arrived on the scene. In addition, I have survived cancer on two occasions fortunately by virtue of early detection at stages where surgery was completely curative, but for this reason, I have taken steps and precautions to avoid any further risks for cancer. My biggest reason for stopping EPO after about one month of therapy was the many articles showing worsening outcomes in the cancer patient population, a now confirmed link directly to EPO.

Davita stands today defending their documented practices of elevated dosages of EPO which earned their company millions of dollars under the old Medicare reimbursement practices for dialysis patients in the category called seperately billable items. At the height of their earnings Amgen's budget in the ESRD program accounted for nearly 40% of the total cost of the entire ESRD program and this fact alone led to the recently implemented Medicare Dialysis Bundle.  Davita of all the companies evaluated does stand alone in the amount of EPO prescribed to its patients despite the known dangers of these drugs prior to 2007. However, Dr Allen Nissenson calls Davita's response to their documented EPO over usage transparent, but in my opinion, that is only if you consider that Davita has no clothes.

The king of EPO in my opinion, stands before us today naked with their greed based prescribing habits fully exposed. Many leaders of industry in similar circumstances caught with dirty hands turn to complete admission of errors and come clean before the public scrutiny that they cannot escape anyway. Davita on the other hand chooses to deflect and attribute their practices to excuses of different times and changing protocols for anemia management:

Guest Commentary: DaVita CMO: We've been transparent

This is not a criticism of the team of reporters who worked hard on a complex, arcane subject that is a narrow part of the clinical care we provide. Your article suggested that we "continue to battle" controversies related to anemia management. In reality, those battles died a natural death in the media long ago.

I am the chief medical officer at DaVita, and prior to that was professor of medicine, director of the dialysis program and associate dean at the David Geffen School of Medicine at UCLA. Because the story could inappropriately alarm thousands of dialysis patients, and call into question the integrity of physicians across the country, we wanted to submit a few additional facts:

• Physicians make prescription decisions. Our affiliated physicians did what they felt was best for each patient every day. Every week. Period.

I would hope that all of the "loyal" Davita nephrologists realize that their CMO just sold them out and declares essentially that the dosages of EPO were simply as prescribed by the individual physicians involved and were not the result of corporate policies. Anyone who has followed the corporate policies of Davita against dissenting physicians who have left Davita understands the aggressive nature of this company against it's own who have left. Davita also continues the barbaric practice of re-use of artificial kidneys for purely monetary savings, any alleged benefits of re-use pales in comparison to the truth of it's dangers.

One of my favorite techs from my in-center days also worked at another privately owned dialysis clinic until shortly after they changed over to Davita leadership. Within a short period of time, the now Davita clinic reduced staffing levels to such dangerously low coverage that this tech quit her Davita job after in her opinion,  being unable to care for her patients in a safe manner. Further, according to the tech, the patients in this unit often suffered at the hands of their prescriptions of dialysis with short dialysis times and high ultrafiltration rates leaving them nauseous, passing out and feeling completely drained. On Monday, Wednesday and Friday in the shared unit that I was in, this same tech observed those symptoms in a well dialyzed population with 4 hours average dialysis times only on rare occasions. The business practices between the Davita unit and the well run unit in her words were night and day.  She no longer ethically could tolerate the Davita "difference" in that specific dialysis unit. She had called me in a bit of distress over the entire situation and left that employment at great financial cost to her family. The ProPublica series divulged dozens of stories equal to that and worse where staffing levels may have contributed to adverse outcomes, a shared trait especially among the for-profit dialysis chains.

I would urge Davita to own up to its aggressive prescribing habits and admit their mistakes instead of trying to offer platitudes of changing times and practices as their excuse in an attempt at transparency. The truth is that their practices netted them millions of dollars for their corporation in the separately billable portion of the old medicare payment system for dialysis but the real story I would like to know is how many thousands of patients might have suffered by these corporate practices at Davita. I would hope that the the Denver Post investigation does not end  only in a series of investigational reports, it is time that the authorities question these practices as well. All just my own opinion on these investigational reports and Davita's responses to date.

 

NBC Report on Dialysis Reveals Continued Media and Nephrology Bias

By Peter Laird, MD

NBC did several background videos on dialysis to accompany their  recent ProPublica feature report which  in my opinion continues the false impression that dialysis is a horrible treatment and renal transplant is our only hope. They correctly pointed out the need for a fistula to avoid complications of catheters, patients fear of needles, risks of infection and reduced clearances, but the primary focus was that of renal transplant implying that renal transplant is the only true hope.  This report based on the ProPublica series returns to the sad bias, in my opinion, now also by NBC of the only hope for patients with CKD-5 is to avoid dialysis and get on the transplant list early.

Visit msnbc.com for breaking news, world news, and news about the economy

Visit msnbc.com for breaking news, world news, and news about the economy

Visit msnbc.com for breaking news, world news, and news about the economy

I would hope that one day, a true and unbiased report on all renal replacement options, including optimal dialysis strategies would be headline news on a national network. Unfortunately, even noting the ProPublica report as the first part of the NBC nightly news that accompanies these videos gives the very biased viewpoint that dialysis is dangerous and that the only hope is renal transplant. Yet, for those that are not part of the 15,000 or so that get a renal transplant in the US each year, we must continue with dialysis as our mainline treatment option.  Yes, for many, renal transplant transforms their life, but so likewise does daily, nocturnal dialysis which is equal in survival to cadaveric transplant, and you don't have to wait to survive 5-8 years to get that survival benefit.  

While I applaud the attention that NBC focused on the ProPublica Dialysis series, it did so in my opinion, by continuing the myth of the gift of life only from renal transplant.  In such, their report will only bring continued death and destruction to hundreds of thousands of dialysis patients because NBC chose to completely ignore optimal dialysis in these 4 segments.  What a failed opportunity.

The dialysis  industry spin continues and people continue to die needlessly because home dialysis options are overlooked at the hands of our nephrologists who fail to inform.  Dr. Barbara Murphy of Mount Sinai Medical Center, in my opinion, is simply the latest biased nephrologist failing American dialysis patients by lack of informed consent of all renal replacement options, even more so on a national news program.  Perhaps she did speak of optimal dialysis, and NBC chose to exclude that discussion in her three segments, I will give her the benefit of the doubt on that issue, but certainly NBC could have chosen to truly educate but did not do so in 4 separate dialysis segments.

You may wish to contact Dr. Murphy at the link above and inform her of your opinion on optimal dialysis issues as I plan to do myself since she failed to make mention of anything outside of in-center dialysis other than renal transplant in three news segments focussed on dialysis especially in light of the recent FHN results.  I will be more than willing to run a full rebuttal by NBC or Dr. Murphy on my blog as well, should they choose to do so.

Not surprisingly, Dr. Barbara Murphy's specialty is renal transplant medicine.  Why would NBC choose a transplant specialist to tell us about dialysis?  Why not a dialysis specialist such as Dr. Chris Blagg, Dr. Robert Lockridge or Dr. John Agar? I can only state that the bias against optimal dialysis appears to run deep in my opinion, even at NBC nightly news. After all, these 4 segments were featuring dialysis, not renal transplant.  Shall the truth ever be told? This is simply my own opinion and my own personal impression of the 4 NBC nightly news segments on Dialysis.

ProPublica Dialysis Facility Tracker Featured on NBC Nightly News

By Peter Laird MD

The recent ProPublica article on dialysis facility reports is featured on a  Brian Williams NBC nightly news special report showing how the lack of information may have contributed to the death of one patient at Dutchess Dialysis Center in Poughkeepsie, NY in 2006.  This is a center that had a much higher than expected rate of death but was listed by CMS as "expected" death rate on its Dialysis Facility compare.

The NBC clip highlights the difficulty that dialysis patients have had obtaining needed information until ProPublica made available the dialysis facility tracker. It further highlights the entire issue of lack of informed consent for dialysis patients to hear of all renal replacement options at the onset of the need for such treatment. Not only do patients rarely hear of home hemodialysis from their health care team, even worse, they previously could not tell which units were better than others to make an informed choice since CMS released only partial data on these facilities and worse yet, hid the true death rates by terms of expected death rate even many times the facility in question had much higher than average death rates.  In such, the ProPublica Dialysis series has entered a new arena of not only investigative reporting, but actual consumer choice by making available this data for the very first time.

ProPublica Introduces Dialysis Facility Tracker

By Peter Laird, MD

Robin Fields of ProPublica introduced the Dialysis Facility Tracker, a website where patients can obtain previously confidential information about their individual dialysis centers.  This will be the best way for patients to be able to compare regional dialysis units to be able to choose the center that has the best outcomes.  CMS has collected this data for years, but has never before made it available.

For years, the government has collected a rich store of data about the performance of individual dialysis facilities. But it has kept nearly all the information secret from those it might benefit most: Patients.

Now ProPublica has obtained this data under the Freedom of Information Act. We are making a comprehensive set of clinic records publicly available for the first time on our website.

Patients and others can search for a clinic and see how it compares on 15 key measures, ranging from mortality and hospitalization to transplant rates and infection control. Also on the site are historical reports dating to 2002.

Patients are already responding and questioning their providers on infection control issues and other parameters now open to the public for the first time ever.  I applaud the efforts by Robin Fields and ProPublica in publicizing the plight of American dialysis patients.  Even congress has taken notice with a letter by Senator Grassley to CMS to answer the issues raised in Robin Field's first article, In Dialysis, Life-Saving Care at Great Risk and Cost.  Dialysis in America is at a cross road and we need to go in the right direction this time.  

Why the ProPublica Dialysis Series Matters

By Peter Laird, MD

The American dialysis industry is in the midst of an ongoing investigative report by Robin Fields of ProPublica, a non-profit journalism outlet.  Dr. Scribner, the father of American dialysis spent the last 30 years of his life advocating for optimal dialysis, yet failed to see this goal realized before his untimely death in 2003.  Many patient advocates have likewise dedicated their lives to bring about access to nocturnal dialysis and daily dialysis for all patients, not just the fortunate few living nearby units that sponsor quotidian dialysis.

Yet, for all of their collective efforts, we are still far from implementation of more frequent and longer duration dialysis as the standard of care. I recently went to an annual physician banquet for my medical clinic and saw many of my colleagues I worked with over the years. I was able to discuss the impact that daily dialysis has in overcoming the usual complications of in-center dialysis, most have never heard of buttonholes or daily dialysis. Unfortunately, none of my colleagues in internal medicine and family practice heard of the Frequent Hemodialysis Network Trial Group results reported at the ASN as well.  

Yet the fact that such a large study so important to the dialysis community didn't even come on the radar screen for the majority of physicians in my medical group underlies the entire visibility issue of dialysis advocacy.  Dialysis patients represent less than 0.2% of the general population of America with only 1% of these patients on home hemodialysis. Politicians are moved by constituents that will vote for their reelection. For dialysis patients, we are a very small voting block with diverse political affiliations.  In addition, the majority of our general dialysis population is not vocal and active in advocacy making our political clout even less than other small but involved groups of patients.

Nephrologists as a group have ignored the benefits of optimal dialysis in contradistinction to their colleagues over seas who long ago embraced the concepts of optimal dialysis.  They have not been swayed by decades of positive reports on nocturnal dialysis and short daily dialysis.  Sadly, in the month since the Frequent Hemodialysis Network results were published, I have seen little movement in response outside of those that were already advocating changes before the study was released.

The National Kidney Foundation, American Association of Kidney Patients and many of the other patient groups for renal patients focus the majority of their efforts on transplant related issues. Celebrity donor and recipients routinely make headline news, yet only ~15,000 of the 450,000 patients on renal replacement therapy have access to successful renal transplants each year.

The ProPublica articles fills the void that our nephrologists, our patient organizations, our primary care physicians, our politicians, our insurance providers, our CMS ESRD program administrators, and even our own uninvolved dialysis patients create by virtue of turning a blind eye to the plight of the average dialysis patient.  Dialysis providers struck down with renal disease uniformly choose home nocturnal dialysis that in many cases they hypocritically denied to their own patients. Even worse is their mute silence about their fellow dialysis cohort left behind in the profit driven dialysis industry once they secure their own treatment.

I welcome the continuing series since it has already stirred the dialysis industry and made them uncomfortable in their complacency even as their public relation campaign mitigates the immediate effects of the articles. Just perhaps, these articles may strike the collective conscience of those who prescribe, over see, pay for, and administer dialysis treatments in a second rate, short and violent manner unique only to America.  

Perhaps it will have no lasting impact as the prior investigative reports from Eichenwald of the NYT and Rita Rubin of USA Today, that soon faded out of memory despite their passion and truthfulness in reporting.  Nevertheless, if nothing else, it will serve as an historical record indicting this generation of dialysis providers and insurers for all posterity.  The epithet of death and demise is not a legacy anyone can cherish. That it shall and already has accomplished.