Quality and equity in dialysis and renal transplantation

Is Dialysis Nephrology's Original Sin?

The introduction of hemodialysis in the 1960s and the subsequent enactment of Medicare coverage in 1972 came to shape the evolution of nephrology as a specialty. The subsequent focus on dialysis care as a principal form of reimbursement led to a host of benefits and challenges for nephrologists. While the specialty initially enjoyed great popularity and exponential growth, a widening schism between researchers and clinicians developed. This limited the growth of robust clinical research in nephrology while dialysis care encumbered clinicians with exhausting travel, routinized rounding schedules, and burdensome navigation of electronic medical record systems. Poor morale and burnout among practitioners, coupled with the ethical issues associated with corporatized medicine have resulted in severe challenges for the specialty including difficulties with recruitment. The history of nephrology elucidates the convergence of medical science, public policy, and corporatization while providing a lens on the wider issues of contemporary American health care. Ongoing efforts to refocus nephrology on preventive care in chronic kidney disease, new diagnostic and treatment modalities, and shifting of dialysis care to nonphysician providers should be accelerated.

A Call to Arms: Economic Barriers to Optimal Dialysis Care

Epidemic growth rates and the enormous cost of dialysis pressure end-stage renal disease (ESRD) delivery systems around the world. Payers of dialysis services can constrain costs through ( 1 ) limiting access to dialysis, ( 2 ) reducing the quality of dialysis, and ( 3 ) placing constraints on modality distribution. In order to secure the necessary resources for ESRD care, we propose that the nephrology community consider the following suggestions: First, future leaders in dialysis should acquire additional advanced training in innovative pathways such as health care economics, business and health care administration, and health care policy. Second, the international nephrology community must strongly engage in ongoing advocacy for accessible, high quality, cost-effective care. Third, efforts should be made to better define and then implement optimal dialysis modality distributions that maximize patient outcomes but limit unnecessary costs. Fourth, industry should be encouraged to lower the unit cost of dialysis, allowing for improved access to dialysis, especially in developing countries. Fifth, research should be encouraged that seeks to identify measures that will reduce dialysis costs but will not impair quality of care. Finally, early referral of patients with progressive renal disease to nephrology clinics, empowerment of informed patient choice of dialysis modality, and proper and timely access creation should be encouraged and can be expected to help limit overall expenditures. Ongoing efforts in these areas by the nephrology community will be essential if we are to overcome the challenges of ESRD growth in this new decade.

How is organ transplantation depicted in internal medicine and transplantation journals

BACKGROUND

In their book Spare Parts, published in 1992, Fox and Swazey criticized various aspects of organ transplantation, including the routinization of the procedure, ignorance regarding its inherent uncertainties, and the ethos of transplant professionals. Using this work as a frame of reference, we analyzed articles on organ transplantation published in internal medicine and transplantation journals between 1995 and 2008 to see whether Fox and Swazey's critiques of organ transplantation were still relevant.

METHODS

Using the PubMed database, we retrieved 1,120 articles from the top ten internal medicine journals and 4,644 articles from the two main transplantation journals (Transplantation and American Journal of Transplantation). Out of the internal medicine journal articles, we analyzed those in which organ transplantation was the main topic (349 articles). A total of 349 articles were randomly selected from the transplantation journals for content analysis.

RESULTS

In our sample, organ transplantation was described in positive terms and was presented as a routine treatment. Few articles addressed ethical issues, patients' experiences and uncertainties related to organ transplantation. The internal medicine journals reported on more ethical issues than the transplantation journals. The most important ethical issues discussed were related to the justice principle: organ allocation, differential access to transplantation, and the organ shortage.

CONCLUSION

Our study provides insight into representations of organ transplantation in the transplant and general medical communities, as reflected in medical journals. The various portrayals of organ transplantation in our sample of articles suggest that Fox and Swazey's critiques of the procedure are still relevant.

Impact of human leukocyte antigen-DR mismatch status on kidney graft survival in a predominantly African-American population under the newer immunosuppressive era

BACKGROUND

Human leukocyte antigen (HLA)-DR has been shown to be immunogenic and associated with poor long-term graft function. However, under potent induction immunosuppression with antithymocyte globulin, the impact of the HLA-DR remains unclear.

METHOD

We reviewed 672 renal transplant recipients who received their transplants between 1998 and 2007. All patients received antithymocyte globulin as induction therapy followed by tacrolimus + prednisone + mycophenolate mofetil for maintenance immunosuppression. We divided the patients into three groups according to HLA-DR mismatch status (zero, one, or two mismatches).

RESULTS

The three groups were different in total number of mismatches, deceased donor transplant, and delayed graft function, respectively. By Kaplan-Meier survival analysis, actuarial graft survival was significantly lower in the HLA-DR two mismatches group (72%) compared to HLA-DR zero mismatches group (78.5%) or HLA-DR one mismatch group (78.5%; P = .05, by log-rank test). Using Cox regression analysis, the risk of graft failure with two HLA-DR mismatches as compared with zero HLA-DR mismatches was 1.6 (95% confidence interval = 1.0-2.44, P = .049). When adjusted for age, wait time, race, type of transplant, retransplant status, T-cell flow crossmatch, delayed graft function, acute rejection, HLA-A and HLA-B, the effect of HLA-DR on survival was not significant (P = .55).

CONCLUSION

The independent effect of HLA-DR mismatches on adverse graft survival is diminished under potent antibody induction and maintenance immunosuppression in our predominantly African-American population.

An empiric estimate of the value of life: updating the renal dialysis cost-effectiveness standard

OBJECTIVES

Proposals to make decisions about coverage of new technology by comparing the technology's incremental cost-effectiveness with the traditional benchmark of dialysis imply that the incremental cost-effectiveness ratio of dialysis is seen a proxy for the value of a statistical year of life. The frequently used ratio for dialysis has, however, not been updated to reflect more recently available data on dialysis.

METHODS

We developed a computer simulation model for the end-stage renal disease population and compared cost, life expectancy, and quality adjusted life expectancy of current dialysis practice relative to three less costly alternatives and to no dialysis. We estimated incremental cost-effectiveness ratios for these alternatives relative to the next least costly alternative and no dialysis and analyzed the population distribution of the ratios. Model parameters and costs were estimated using data from the Medicare population and a large integrated health-care delivery system between 1996 and 2003. The sensitivity of results to model assumptions was tested using 38 scenarios of one-way sensitivity analysis, where parameters informing the cost, utility, mortality and morbidity, etc. components of the model were by perturbed +/-50%.

RESULTS

The incremental cost-effectiveness ratio of dialysis of current practice relative to the next least costly alternative is on average $129,090 per quality-adjusted life-year (QALY) ($61,294 per year), but its distribution within the population is wide; the interquartile range is $71,890 per QALY, while the 1st and 99th percentiles are $65,496 and $488,360 per QALY, respectively. Higher incremental cost-effectiveness ratios were associated with older age and more comorbid conditions. Sensitivity to model parameters was comparatively small, with most of the scenarios leading to a change of less than 10% in the ratio.

CONCLUSIONS

The value of a statistical year of life implied by dialysis practice currently averages $129,090 per QALY ($61,294 per year), but is distributed widely within the dialysis population. The spread suggests that coverage decisions using dialysis as the benchmark may need to incorporate percentile values (which are higher than the average) to be consistent with the Rawlsian principles of justice of preserving the rights and interests of society's most vulnerable patient groups.

Effect of dialysis center profit-status on patient survival: a comparison of risk-adjustment and instrumental variable approaches

OBJECTIVE

To compare the estimated effects of dialysis center profit status on patient survival using alternative estimation strategies with retrospective data.

DATA SOURCES/STUDY SETTING

Patient and provider-level retrospective data from the United States Renal Data System (USRDS), 1996-1999.

STUDY DESIGN

Observational risk adjustment and instrumental variable methods.

DATA COLLECTION/EXTRACTION METHODS

Study collected measures from various USRDS files describing clinical characteristics, survival, and the profit status of the initial dialysis center for incident end-stage renal disease (ESRD) patients aged 67+. USRDS facility files were used to assess dialysis center profit status and measure patient distances to dialysis centers.

PRINCIPAL FINDINGS

Found survival effect related to profit status in the range of previous research using risk-adjusting covariates similar to those used in previous models. Adding further risk-adjusting covariates halved this effect. The relative proximity of for-profit and nonprofit dialysis centers to the patient residence was the strongest determinant of the profit status of the patient's initial dialysis center. The effect of profit status on survival was eliminated using the two-stage least squares variant of instrumental variable estimation with the relative proximity of for-profit and nonprofit dialysis centers to the patient's residence as the instrument.

CONCLUSIONS

Using only the variation in initial dialysis center profit status that was related to the relative proximity of for-profit and nonprofit dialysis centers to the patient, we found no relationship between dialysis center profit status and patient survival. These results are in contrast to results obtained using risk-adjustment methods with a limited set of risk-adjusting covariates.

Allocation of deceased donor kidneys: past, present, and future

The manner in which deceased donor kidneys are allocated has broad relevance to the care of patients with end-stage renal disease. An algorithm governing the allocation of deceased donor kidneys has been applied in the United States since 1987. Adjustments were made to facilitate the national sharing of highly matched kidneys, but the main components of the algorithm remained largely unchanged. In ensuing years, the number of patients on the waiting list has increased steadily while the supply of kidneys has remained constant. The waiting time for an organ now is measured in years, and the allocation of organs has become unpredictable. As of October 2002, several important changes have been made to the algorithm. These changes are designed to increase the relative number of minority patients who undergo transplantation and the use of extended-criteria donor kidneys. They also have practical implications for the management of patients on the waiting list. The rationale behind these changes is discussed in the context of the ethical underpinnings of kidney allocation.

Components of culture in health for medical students' education

Medical educators across the United States are addressing the topics of culture, race, language, behavior, and social status through the development of cross-cultural coursework. Dramatic demographic changes and nationwide attention to eliminating racial and ethnic health disparities make educating medical students about the importance of the effects of culture on health a 21st-century imperative. Despite the urgent need for including this topic material, few medical schools have achieved longitudinal integration of issues of culture into four-year curricula. The author makes the practical contribution of describing key themes and components of culture in health care for incorporation into undergraduate medical education. These include teaching the rationale for learning about culture in health care, "culture basics" (such as definitions, concepts, the basis of "culture" in the social sciences, relationship of culture to health and health care, and health systems as cultural systems), data on and concepts of health status (including demographics, epidemiology, health disparities, and the historical context), tools and skills for productive cross-cultural clinical encounters (such as interviewing skills and the use of interpreters); characteristics and origins of attitudes and behaviors of providers; community participation (including the use of expert teachers, community-school partnerships, and the community as a learning environment); and the nature of institutional culture and policies.