Dialysis Unplugged: "Cutting off Your Nose to Spite Your Face"

I believe that there is a common thread that connects many of the complaints that patients have about their dialysis care (see comments to Is Change Possible?). This thread is the absence of a patient-centered approach.

The way that dialysis facilities are set up is to maximize efficiency - their efficiency. In most units, the first shift of patients on dialysis gets going around 6 am and finishes up around 10:30 or 11 am and then the second shift of patients gets on. There isn’t much room for extended dialysis treatments or for additional treatments. The facility is set for a Monday-Wednesday-Friday shift or a Tuesday-Thursday-Saturday shift. Most nephrologists round each week but they round on an average of 10 to 20 patients per shift, but frequently round at multiple units. Dialysis rounds are focused on biochemical and hematological outcomes. Likewise, the dialysis quality meeting also focuses on achieving specific laboratory outcomes. Most units don't have an exam room for a private evaluation of a patient.

Where’s the time or place for a patient-centered approach to dialysis care?

In a thought-provoking article titled "Patient-Centered Care: What It Means And How To Get There", James Rickert, an orthopedic surgeon discusses the ins-and-outs of patient-centered care.

Rickert writes: “the first step in understanding patient-centered care is an understanding that patients must be asked to rate or judge their health care; providers often believe that we know everything about our patients and their care, but we are simply unable to accurately assess our patients’ perceptions of their care–what is important to them, how well we are delivering care, what factors in our patient care improve outcomes.  We need to attempt to move from “what’s the matter” with our patients to “what matters” to our patients.”

Rickert goes on: “patient-centered care is a method of care that relies upon effective communication, empathy, and a feeling of partnership between doctor and patient to improve patient care outcomes and satisfaction, to lessen patient symptoms, and to reduce unnecessary costs.  Doctors are able to help their patients become more compliant with treatment and active in the management of their diseases.  Patients also feel more satisfied with the care that they are receiving.  This is all achieved while reducing the need for expensive prescriptions, testing, referrals, and hospitalizations.  It is a low-tech humanistic approach to medicine with the option of using high tech medicine when necessary, but not as a substitute for the fundamental bond between patient and doctor.  In many ways, it is the cure for what ails our health care system.”

Drawing some important parallels from Rickert’s article about the obstacles to patient-centered care and applying them to our dialysis patients. The potential solutions might be:

1. Increase current reimbursement levels for nephrologists to reflect the care of complex patients. I know I am "putting myself out there" to the criticism of arguing for more money for nephrologists rather than better care for patients, but truthfully there has been an historic underpayment for nephrology care, which has taken it's toll on patient care. The way to fix this is to reimburse nephrologists properly for the time that they spend taking care of very complex patients.

Fig.1: Outpatient nephrologist fees are <10% of total dialysis costs

There is no debate about the fact that dialysis patients are generally older, have several co-morbidities, are on many medications, and are frequently hospitalized. The nephrologist frequently becomes the principal care giver. However, the cost of the nephrologists professional fee is a fraction of the total cost of a dialysis to the payor; and, it doesn't reflect the amount of time and effort that goes into patient care and coordination (Fig.1). Being frugal with nephrologists means that less time is spent with individual patients, reducing the time for emotional support. All of this degrades the patient experience. As well, nephrologists have less time for coordination and thinking pro-actively about how to keep the patient out of the hospital (note: one-half of dialysis patient costs relate to hospital charges). Not paying nephrologists appropriately for the time that is really needed to take a patient-centered approach is a case of “cutting your nose to spite your face”.  

2. Change the focus of quality improvement from monitoring of "processes of care" or "laboratory outcomes" to more patient-cenered measures. A patient-centered approach would include, measuring quality of life or depression or rehabilitation potential. None of these are done presently. Therefore, nephrologists tend to focus on facility-centric rather than patient-centered factors.

3. Incentivize nephrologists to take care of their patients when these patients are hospitalized. Increasingly, like generalists, nephrologists are turning over the inpatient care of patients to hospitalists. This has already happened at my hospital. While hospitalists are skillful at taking care of patients, the addition of another doctor further fragments the care of a complex dialysis patient. Indeed, Rickert adds to this by writing: “In addition to the fragmentation which hospitalists bring to patient care, one of the reasons hospitals hire them is for the express purpose of reducing patient days per admission.  While this may be a worthy goal, and it is certainly financially beneficial to hospitals, it may or may not improve the care which patients receive, and it is antithetical to patient centrism, which puts patient concerns at its center.”

Perhaps "Accountable Care Organizations" or ACO’s will be the way more patient centered care will emerge, as Rickert suggests. For our dialysis patients I'm not sure ACOs are the answer, but I hope that they are.

The bottom line is that we too should be pursuing patient-centered care, but in addition to reimbursing more dialysis and home dialysis, nephrologists should be properly rewarded (while "holding their feet to the fire"), patient centered quality measures should be developed, and fragmentation in care should be resisted.