Dialysis Unplugged: Is Change Possible?

Without doubt the people who have commented that we need to do more frequent and/or longer dialysis to improve the lives of patients are right.

Some have suggested that nephrologists should have made it happen – implying that we have been too timid in doing what is right. I don’t agree. As I have already discussed, to have change in dialysis practice at the national level needs more than just pointing the finger at nephrologists and saying “do it”. Nor will it fly, in my view, to say "nephrologists are not leading change because they are greedy or have conflicts of interest." Sorry folks, while these arguments might resonate with some; in my mind, they won't change dialysis practice.

The leadership and change management guru, John Kotter, a professor at Harvard Business School provides one way to think about tactics that, he suggests, drive change (see his book from 1996: “Leading Change”). Here I've applied this to dialysis practice:

Source: http://www.ideachampions.com

1. Creating Urgency

For there to be a change in dialysis practice, such that the mantra "more-dialysis-is-better" results in widespread modification in the dialysis prescription, there needs to be consensus among providers and patients. One way to make this happen is to gather evidence that supports more dialysis. We have some evidence (discussed here), but we need more: bigger trials, harder and cleaner endpoints, and formal demonstration of cost-effectiveness. By showing mortality benefit that could be generalizable to the dialysis population as a whole there becomes an urgency to change what we currently do. 

2. Forming a Powerful Coalition

Key organizations have to re-align. Instead of the current coalition of professional, patient advocacy, dialysis provider and pharma companies aligning under the Kidney Care Partners (KCP) umbrella, a new coalition of nephrology professional and patient advocacy organizations needs to form. The current coalition represents the spectrum of nephrology interests, but it mixes up commercial interests with patient interests. We need a coalition aligned with patient interests for better outcome. For example, it may be more expensive to have every-other-day dialysis compared to the current regimen. The benefits of every-other-day dialysis -- particularly financial - may not be seen by the dialysis providers. Forming a new powerful coalition that focuses on the long-term interests of patients is in the interest of both patients and nephrology professionals, but as callous as it may sound, may not be in the commercial interest of dialysis providers.

3. Creating a Vision for Change

A clear vision is needed. What do the patient and nephrology community want to do? Is the goal quotidian (or daily) dialysis? Or is it every other day (EOD) therapy? Is the vision for nocturnal dialysis or short daily dialysis? Coalescing around a singular goal with an associated vision would be good.

4. Communicating the Vision

The vision needs to be communicated via key opinion leaders speaking and writing about this issue. Having national or international societies embrace the vision woudn’t do much harm either. The media needs to get involved to promote the vision, highlighting that it is based on evidence from well conducted trials.

5. Removing Obstacles

Getting Medicare to reimburse "more dialysis" would clearly be a powerful driver for change. After all, Medicare (CMS actually) is the principal payer for dialysis in the US. Before this happens, CMS has to agree that there is evidence to change the current reimbursement for dialysis. Establishing consensus over the evidence requires writing to the Medicare Evidence Development and Coverage Advisory Committee (MEDCAC) and asking them to fomally review the evidence. They would probably set up a technical review. Another option could involve lobbying for the FDA to start regulating dialysis itself (as I have argued elsewhere, link 1, link 2). In Europe - UK as an example - getting the NHS to buy-in would be critical. Lastly, one could lobby political leaders in Congress and the Senate who could then pressure CMS.

6. Creating Short-term Wins

Demonstrating that more dialysis is technically and practically possible for some patients has already been done. Demonstrating the feasibility of every other day in-center dialysis as an option for everyone can be done but requires a demonstration project(s) or pilot programs.  

7. Building on the Change

Expanding more dialysis to include all patients – elderly and the disabled - rather than in select patient populations would be important. Getting professional societies on board would make a difference. Showing the benefits of "more-dialysis" on outcomes such as rehabilitation potential, depression, physical and mental domains of quality of life, hospitalization rates, etc would build on the agenda for change.

8. Anchoring the Changes

Developing guidelines that anchor evolving clinical practice would be important. Creating performance measures through the National Quality Forum and other like bodies to monitor whether providers are complying with  changes in practice.  Rewarding providers through incentives would also help anchor changes.