Two articles—in February 2019 by Mahesh Krishnan and Kent Thiry1 and by Ron Shinkman in June 20162—both published as New England Journal of Medicine Catalyst essays, coupled with a powerful critique in 2010 by Robin Fields in the Atlantic3, discuss the current state of dialysis care in the United States. Krishnan and Thiry, both senior leaders at DaVita, argue that innovation is alive in dialysis care and that much progress has been made. In contrast, Shinkman and Fields both make the case that low quality care and poor outcomes are commonplace and that dialysis is broken.
Krishnan and Thiry cite implementation science as a form of innovation that has produced results: “Dialysis care also has improved significantly over the past century through implementation science, providing dialysis patients with broader access to care, improved outcomes, and a better overall experience.” They point to a reduction in mortality as evidence that the current system is working.
In her article in the Atlantic3 titled “God Help You. You’re on Dialysis,” Robin Fields writes:”[Yet] the United States continues to have one of the industrialized world’s highest mortality rates for dialysis care. Even taking into account differences in patient characteristics, studies suggest that if our system performed as well as Italy’s or France’s, or Japan’s, thousands fewer kidney patients would die each year.” Field provides examples of poor quality of care in dialysis facilities and makes a powerful case for the system being broken.
A speech by Alex M. Azar II, secretary of the Department of Health and Human Services (HHS), in March 2019 at the 6th Annual National Kidney Foundation (NKF) Kidney Patient Summit4 pushes for reform. Secretary Azar says that dialysis care does lack innovation. Coming from the US Government, his statement is striking. He points to incentives currently in place supporting the status quo, and says that HHS will aim to prioritize reform in Medicare reimbursement in order to incentivize more treatment options and greater innovation.
Changes in dialysis care and reimbursement are long overdue. In addition to the views of patients and families reported in the media, nephrologists like myself see that dialysis care needs reform.The steep cost of treatment(Medicare’s cost of treatment each year for just dialysis care is about $34 billion) has not been matched by improvements in the quality of life of patients on dialysis, nor by the development of new treatments. Krishnan and Thiry can argue that innovation in developing new devices has been constrained by regulation, but the fact is that very little has changed in dialysis care over the past two decades. This is amid healthy profits for large dialysis organizations that care for the majority of dialysis patients—just look at the balance sheet of DaVita or Fresenius.
Over the past few decades, the nephrology community has not been standing still. The National Institutes of Health has invested millions of dollars to fund both mechanistic studies and trials evaluating the effects of various interventions. Companies have developed new medicines. Dialysis companies have improved processes, including greater integration of care. The American Society of Nephrology has stepped in to develop synergies by launching the Kidney Health Initiative. And, the NKF has continued to push educational initiatives. All of this is laudable. Still, progress has been slow.
What the dialysis world needs is a “shot in the arm.” It needs the equivalent of the Cancer Moonshot, a $1.8 billion dollar initiative approved in December 2016 to find a cure for cancer. The Dialysis Moonshot could focus on strategies to improve the quality of life and clinical outcomes in dialysis patients. A focused effort that is well funded could make the difference. A blue ribbon panel could develop a list of priorities for the Dialysis Moonshot. Given the large cost of dialysis care, a $2 billion investment is a relatively small price to pay for future large benefits.
The fact is that we need a Dialysis Moonshot because current approaches are not working. Many therapeutic interventions that seem to be efficacious in nondialysis patients don’t seem to be effective in dialysis patients. Take, for example, the use of statins in dialysis patients. Despite cardiovascular events being the leading cause of death in dialysis patients, statins, which have been proven to be effective in nondialysis CKD patients and those with normal kidney function, do not seem to be effective in dialysis patients. Correcting anemia with erythropoietin, repairing abnormalities in metabolic bone disease parameters, and treating hypertension are all also challenging in dialysis patients.
New approaches are needed. As Albert Einstein is quoted as saying: “The definition of insanity is doing the same thing over and over again, but expecting different results.”
1. Krishnan M, Thiry K: Innovation in Dialysis: Continuous Improvement and Implementation NEJM Catalysis Feb 27 2019. Accessed at https://catalyst.nejm.org/innovation-dialysis-continuous-improvement/www.nytimes.com/2019/02/15/health/dialysis-kidney-disease.amp.html
2. Shinkman R: The Big Business of Dialysis Care. NEJM Catalyst June 9, 2016 Accessed at https://catalyst.nejm.org/the-big-business-of-dialysis-care/
3. Fields R: God Help You. You’re on Dialysis. Atlantic Dec 2010 Accessed at https://www.theatlantic.com/magazine/archive/2010/12/-god-help-you-youre-on-dialysis/308308/