Standards of Care in Colorado

[cschwab]

We at DialysisEthics.org have decided to push for Standards of Care here in Colorado.  The following is what has resulted after a meeting back in June with Davita representatives to discuss conditions in dialysis that left many unanswered questions (in attendance were: two representatives from Davita, Colorado State Representative John Kefalas, Della from DialysisEthics.org, and myself).  Also we have contacted Northwest Kidney Centers and received information on patient/staff ratios, Dr. John Agar from Home Dialysis Central has provided information, and we have been in contact with DCI.

The following has resulted after the above inquiries and years of watching the goings-on in dialysis.  This list is a wish-list that can be added to, subtracted from, revised, and definitely commented on.  It could result in a Colorado state bill, but State Representative John Kefalas hasn't committed to anything - however, he is very aware and interested in this.  (link is provided at end of post to flyer in pdf form)

Possible Standards of Care in Colorado

A group of us have been working on possible Standards of Care here in Colorado for several months.  The following are 5 items we have come up with for better care in dialysis.  To add items, comment on the following items (either in favor or not), or to seek more information email can be sent to the following people:

Main contacts:
Chris Schwab, DialysisEthics.org:  chriss.deo.ceo@gmail.com
Front Range Kidney Patient Association:   gp134b@yahoo.com
Alternate contact: (John has asked that the "Main Contacts" filter most emails and contacts, however if something is better directed to him he can be contacted)            
Colorado State Representative John Kefalas:  john.kefalas.house@state.co.us                                            ph. 303-866-4569 (office),  970-221-1135 (home)

1) Increased time on dialysis
 How:                                                                                                                                                                            
Run pump speeds between 300 and 325 ml/min - as they do in Australia.  Increase time on dialysis and keep standardized Kt/V the same.  And possibly use HDP to figure dialysis adequacy:
HDP:  http://www.therenalnetwork.org/qi/resources/HDP.pdf
Dr. John Agar and discussion on pump speeds and time on dialysis: http://forums.homedialysis.org/showthread.php/2961-Hdp
Why:                                                                                                                                                        
"Disappearance of postdialysis fatigue, better dialysis adequacy, a higher removal of middle and large molecules, a reduction of phosphate binders, improvement of status nutritional, and an important reduction of cardiovascular risk factors " http://www.ncbi.nlm.nih.gov/pubmed/12787423
"Just as speed on the road kills, so it does in hemodialysis." Dr. Carl Kjellstrand, http://www.dialysisethics2.org/index.php/Our-Concerns/dr-carl-kjellstrand.html
"Japan, Europe, Australia and New Zealand have long recognized the survival benefits of longer, slower and gentler dialysis compared to our American style violent sessions." Peter Laird, MD:  
http://www.billpeckham.com/from_the_sharp_end_of_the/2010/10/do-we-need-to-abandon-high-ultrafiltration-rates-in-america.html%20

OR:
Have Medicare pay for 85% of dialyzors getting at least 4 hours of treatment 3 times a week  -as they do in Germany and Japan.

"In Japan and Germany, one of the pay for performance targets for dialysis is that 85% of dialyzors must be getting at least 4 hours of treatment 3x/week (this would translate to 2 hours x 6 days a week). I think that would be an excellent goal worth working toward here, particularly in light of the DOPPS (Dialysis Outcomes & Practice Patterns Study) data among 22,000 or so dialyzors that found a 30% drop in the risk of death for folks who got at LEAST 4 hours of treatment. IMHO, there is no excuse for anyone to be getting less than this, regardless of body size. It is not possible to get too much dialysis (though it is possible to remove too much water and leave people feeling wretched--this is actually quite common)."  http://forums.homedialysis.org/showthread.php/2667-Dialysis-Industry-May-Expand-as-Study-Sways-Medicare
 
2) Standardized Patient/Staff ratios:  
Standard community dialysis units in Colorado would have a 40/60 percent ratio of nurses to techs.  Units with Special Care patients and those with 12 or less patients would have a 50/50 percent ratio of nurses to techs. The ratio of staff to patients would be 1/3.                     (Numbers obtained from Northwest Kidney Centers and Arlene Mullin, former dialysis tech and a founder of DialysisEthics)

3) Reuse would be abolished
Why:                                                                                                                                                                &nb sp;
1. "Dialysis in freestanding facilities reprocessing dialyzers with peracetic/acetic acid may be associated with worse survival than dialysis in free-standing facilities not reprocessing dialyzers" Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Medical Center, Philadelphia 19104-6021, USA.  http://www.dialysisethics2.org/forum/index.php?topic=58.0
2. Human error  with reuse hasn't been eliminated after years of trying to get it right:                                                                                        "In April, however, Price

[cschwab]

Quote of the day:

Dori Schatell
Executive Director
The Medical Education Institute, Inc. and Home Dialysis Central

When asked:
"So are other countries doing more frequent dialysis - Italy, Australia maybe?"

Dori:
"I'm not aware that ANY other country has upped the frequency of dialysis. But what they HAVE done--and it has saved countless lives--is they do longer HD runs. In the US, per the DOPPS study (Saran R et al, Kidney Int. 2006, 69:1222-28), the average treatment time was just 211 minutes (3.5 hours), vs. 232 minutes in Europe (3.86 hours) and 244 minutes in Japan (4 hours). In that study, getting a minimum of 4 hours of treatment improved survival by 30%--and each extra 30 minutes beyond that further improved survival by another 7%. I've seen that survival on dialysis in Japan is triple that of the US, and in Europe it is double. Time matters, too! So, in the U.S., we have two marks against us: too-short treatments AND the 2-day gap. In other countries, they only have the gap.

For logistic/transportation reasons, I think it will be very difficult for in-center programs to do a 2-week rotation of Mon-Weds-Fri-Sun-Tues-Thurs-Sat to get rid of the 2-day killer gap. (Some transportation companies only operate on weekdays.) They'd have to be 100% in or 100% out--imagine trying to run a clinic where some folks come every other day and some 3x/week. The scheduling would be a nightmare! So, more frequent treatments are best done at home, or perhaps in areas with multiple clinics, some could offer 3x/week and some every-other-day..."
http://forums.homedialysis.org/showthread.php/3161-The-Long-Dialysis-Weekend-Might-Kill-You-But-We-Won-t-Change?p=21681&mode=linear#post21681

[cschwab]

A retired dialysis nurse I know looked over the proposed Standards of Care and mentioned it looked like they are coming along nicely.  She did mention however that Fresenius hadn't done transfusions for quite a while (15 years or so).  May have to find out if they are starting up again.  I've contacted Roberta Mikles from QualitySafePatientCare about it.