Reasons for the Decrease in Peritoneal Dialysis Utilization in the US
Reasons for the Decrease in Peritoneal Dialysis Utilization in the US
A major problem for advocates for peritoneal dialysis (PD) is the decline in prevalent and incident end-stage renal disease (ESRD) patients treated with PD as reported in the US Renal Data System (USRDS) database. Thus, the 2007 USRDS report notes that less than 8% of both incident and prevalent ESRD patients were treated with PD in 2005. The reasons for this decline are not obvious and have led to informal discussions among a group of nephrologists to discuss this issue and address the reasons for this decline. This group has focused attention on a variety of arenas that they feel need to be addressed.
Before discussing the groups' suggestions, it should be noted that the United States ranks well below many other countries in North America (eg, Canada and Mexico), Europe (eg, the United Kingdom and The Netherlands), and Asia (eg, Hong Kong) in terms of PD utilization. Furthermore, the percent of patients on PD varies widely by state, with some states, such as Alaska, Idaho, and Connecticut, having about 20% of their ESRD patients on PD. In addition, when nephrologists in the United States and New England were questioned about what percent of ESRD patients they thought should be maintained on PD, the nephrologists indicated between 30% and 35%, similar to the numbers reported by Canadian and UK nephrologists. The major reasons for the decline in PD utilization noted by the group are summarized in the Table .
One of the major reasons for the decline in PD involves the structure and organization of PD units. The majority of units provide care for less than 10 patients, and over one third of PD patients in the United States are cared for in units with less than 20 patients. This is important because studies have shown that technique failure rates are higher in smaller sized facilities, perhaps reflecting the lack of experience and lack of adequate staff to care for complex patients. The important role of nursing and the need for an adequately trained staff to take calls and support patients at home needs to emphasized. Psychosocial support of patients and their family is also essential for any home-based therapy and requires that the social worker be actively engaged in patient care. Depression, for example, has been associated with peritonitis rate in PD patients and thus needs to be carefully screened for.
Appropriate Continuous Quality Improvement programs need to be established involving all staff members (physicians, social workers, dieticians, nurses, and physician extenders). Domains that need to be routinely reviewed include peritonitis rates, exit site infections, catheter-related problems, patient satisfaction with care, patient and their family's quality of life, and whatever other issues may present in an individual facility. PD units need the staff to adequately perform these Continuous Quality Improvement programs.
Linking to and supporting chronic kidney disease (CKD) education programs need to be emphasized. There is high turnover of PD patients. Taking into account transplantation, death, and transfer to hemodialysis (HD), only 50% of PD patients can be expected to be on the therapy 2 years after they start. Thus, there needs to be a continued influx of patients and active training to maintain an adequate census to deliver high quality care. Data from The Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD) database suggest that if CKD patients are offered all options, 38% of incident patients will opt for and start PD. The United States does not have a good record at providing CKD education. No funding is provided to support this education, and it must be done by physicians at the time of routine office visits. Thus, when patients who had just started dialysis in southern California were asked if they were offered PD, only 35% said yes. And data presented at the 2008 Annual Dialysis Conference pointed out that when patients who were being cared for by nephrologists were asked about their knowledge of PD, the majority did not report having information about this therapy.
Another area that needs to be addressed involves problems with the training of fellows for PD. The majority of fellows have limited exposure to PD patients during their training and are not adequately trained to manage a PD unit and care for PD patients. It is important that the quality of training be re-examined and basic standards of training in PD be established. If training cannot be provided at a given institution, then fellows should be assigned to rotations at institutions with well established PD programs.
Physician reimbursement for PD has been reduced and higher reimbursement can be obtained by seeing HD patients weekly than with monthly PD visits. This schema seems unreasonable given the effort that needs to be provided to support a home-based therapy -- support for not only the patients but the dialysis staff as well. Efforts need to be directed towards addressing this imbalance.
New PD solutions have been introduced slowly in the United States. Icodextrin was released for use in the United States several years after European facilities had benefited from the availability of this solution. Amino acid-based solutions are not available in the United States, and the potential benefits of the newer more biocompatible solutions are being explored in Europe and Asia but are still not available in the United States. Unfortunately, the expense of introducing solutions in the United States and the regulations of the US Food and Drug Administration have limited US nephrologists. Instead of being at the forefront of technological change, we are now watching new developments be explored in other parts of the world.
Last is the issue of physician bias. The question of higher mortality rates for PD patients compared with HD patients has been debated for many years. Certainly for younger patients with no comorbidities, this is not the case in the United States. Data from other countries' registries indicate a lower mortality rate for PD patients for the initial 2 to 3 years of therapy, and recent data from the USRDS suggest that the mortality rate for PD patients has been declining more rapidly than the mortality rate for HD patients.
In summary, it is important that the problem of PD utilization in the United States be addressed. The current low utilization does not appear to be what physicians or patients want and is different from the pattern that is observed in many other countries. Addressing the problem will require that there be a re-examination of the organization of PD units, an emphasis on patient education, a reassessment of nephrology training, review of physician reimbursement for home and in-center HD, and technological exchange to permit the exploration of newer techniques.
A major problem for advocates for peritoneal dialysis (PD) is the decline in prevalent and incident end-stage renal disease (ESRD) patients treated with PD as reported in the US Renal Data System (USRDS) database. Thus, the 2007 USRDS report notes that less than 8% of both incident and prevalent ESRD patients were treated with PD in 2005. The reasons for this decline are not obvious and have led to informal discussions among a group of nephrologists to discuss this issue and address the reasons for this decline. This group has focused attention on a variety of arenas that they feel need to be addressed.
Before discussing the groups' suggestions, it should be noted that the United States ranks well below many other countries in North America (eg, Canada and Mexico), Europe (eg, the United Kingdom and The Netherlands), and Asia (eg, Hong Kong) in terms of PD utilization. Furthermore, the percent of patients on PD varies widely by state, with some states, such as Alaska, Idaho, and Connecticut, having about 20% of their ESRD patients on PD. In addition, when nephrologists in the United States and New England were questioned about what percent of ESRD patients they thought should be maintained on PD, the nephrologists indicated between 30% and 35%, similar to the numbers reported by Canadian and UK nephrologists. The major reasons for the decline in PD utilization noted by the group are summarized in the Table .
One of the major reasons for the decline in PD involves the structure and organization of PD units. The majority of units provide care for less than 10 patients, and over one third of PD patients in the United States are cared for in units with less than 20 patients. This is important because studies have shown that technique failure rates are higher in smaller sized facilities, perhaps reflecting the lack of experience and lack of adequate staff to care for complex patients. The important role of nursing and the need for an adequately trained staff to take calls and support patients at home needs to emphasized. Psychosocial support of patients and their family is also essential for any home-based therapy and requires that the social worker be actively engaged in patient care. Depression, for example, has been associated with peritonitis rate in PD patients and thus needs to be carefully screened for.
Appropriate Continuous Quality Improvement programs need to be established involving all staff members (physicians, social workers, dieticians, nurses, and physician extenders). Domains that need to be routinely reviewed include peritonitis rates, exit site infections, catheter-related problems, patient satisfaction with care, patient and their family's quality of life, and whatever other issues may present in an individual facility. PD units need the staff to adequately perform these Continuous Quality Improvement programs.
Linking to and supporting chronic kidney disease (CKD) education programs need to be emphasized. There is high turnover of PD patients. Taking into account transplantation, death, and transfer to hemodialysis (HD), only 50% of PD patients can be expected to be on the therapy 2 years after they start. Thus, there needs to be a continued influx of patients and active training to maintain an adequate census to deliver high quality care. Data from The Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD) database suggest that if CKD patients are offered all options, 38% of incident patients will opt for and start PD. The United States does not have a good record at providing CKD education. No funding is provided to support this education, and it must be done by physicians at the time of routine office visits. Thus, when patients who had just started dialysis in southern California were asked if they were offered PD, only 35% said yes. And data presented at the 2008 Annual Dialysis Conference pointed out that when patients who were being cared for by nephrologists were asked about their knowledge of PD, the majority did not report having information about this therapy.
Another area that needs to be addressed involves problems with the training of fellows for PD. The majority of fellows have limited exposure to PD patients during their training and are not adequately trained to manage a PD unit and care for PD patients. It is important that the quality of training be re-examined and basic standards of training in PD be established. If training cannot be provided at a given institution, then fellows should be assigned to rotations at institutions with well established PD programs.
Physician reimbursement for PD has been reduced and higher reimbursement can be obtained by seeing HD patients weekly than with monthly PD visits. This schema seems unreasonable given the effort that needs to be provided to support a home-based therapy -- support for not only the patients but the dialysis staff as well. Efforts need to be directed towards addressing this imbalance.
New PD solutions have been introduced slowly in the United States. Icodextrin was released for use in the United States several years after European facilities had benefited from the availability of this solution. Amino acid-based solutions are not available in the United States, and the potential benefits of the newer more biocompatible solutions are being explored in Europe and Asia but are still not available in the United States. Unfortunately, the expense of introducing solutions in the United States and the regulations of the US Food and Drug Administration have limited US nephrologists. Instead of being at the forefront of technological change, we are now watching new developments be explored in other parts of the world.
Last is the issue of physician bias. The question of higher mortality rates for PD patients compared with HD patients has been debated for many years. Certainly for younger patients with no comorbidities, this is not the case in the United States. Data from other countries' registries indicate a lower mortality rate for PD patients for the initial 2 to 3 years of therapy, and recent data from the USRDS suggest that the mortality rate for PD patients has been declining more rapidly than the mortality rate for HD patients.
In summary, it is important that the problem of PD utilization in the United States be addressed. The current low utilization does not appear to be what physicians or patients want and is different from the pattern that is observed in many other countries. Addressing the problem will require that there be a re-examination of the organization of PD units, an emphasis on patient education, a reassessment of nephrology training, review of physician reimbursement for home and in-center HD, and technological exchange to permit the exploration of newer techniques.
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