Friday, December 1, 2017

Home Hemodyalysis: The Unknown Option


            Kidneys are very important, relatively easily damaged, and don’t regenerate. Chronic Kidney Disease (CKD) can develop a variety of ways, and is a present and growing public health concern in the United States. As we’ve not only begun developing CKD more frequently, but also living longer, end-stage renal disease (ESRD) has begun to be more prevalent as well. The treatment options for ESRD are pretty limited: Dialysis or a kidney replacement. Kidney replacements themselves are complicated, so I’ll leave that discussion for another blog. Dialysis, technically called Hemodyalysis, is the far more common option of the two, but it’s not preferred.
            Hemodialysis (HD) treatment relies on an external machine to do the work of individuals’ kidneys. HD machines filter patients’ blood (supplied via IV) over ~four hours, and must be done ~three times a week. As you can imagine, this puts a huge burden on patients in time and lifestyle loss.
            Enter Home Hemodyalysis (HHD). This treatment is completed in patients’ homes, alleviating many of the burdens of HD centers. There are no lines or scheduling, and treatment can even be done at night. Research has shown a positive correlation between HHD (especially nighttime HHD) and a decrease in hypertension, left ventricular mass, and patient mortality rates, as well as an increase in overall patient health scores. Despite all of these benefits, HHD is by less than 10% of dialysis patients.
            HHD sounds amazing, so why isn’t it used more frequently? My first assumption is that Medicare must not cover it, but that’s very incorrect. Medicare is actually trying to increase HHD use to 25%, but is having little success. HHD is actually cheaper than in-center HD, which Medicare loves, but providers may not. Simply put, physicians are not reimbursed as much when patients use HHD, so many don’t discuss it. As one paper aptly pointed out, “It is unclear how the regulatory body expects the patient to advocate for themselves if they do not know whether the HHD option exists.” Now, to be fair, HHD is also a little more expensive upfront for patients. Home plumbing and electrical modifications must be done, but these costs would likely be offset by improved lifestyle and time to work. I rarely think it’s appropriate for patients request specific treatment from providers, but in this case, physicians are breaking ethical principles by not informing patients about HHD.



Sources

Dialysis. (2017, June 14). Retrieved December 01, 2017, from https://www.kidney.org/atoz/content/dialysisinfo 

Hajj JJ, Laudanski K. Home Hemodialysis (HHD) Treatment as Effective yet Underutilized            Treatment Modality in the United States. Healthcare (Basel). 2017 Nov 28;5(4). pii: E90. doi: 10.3390/healthcare5040090. Review. PubMed PMID: 29182543.

2 comments:

  1. Caleb, I completely agree that this is one of the few circumstances in which patients can make specific treatment requests from providers. These physicians are breaking ethical principles and should be required to give patients every possible treatment options.

    When it comes to a patient's care, the information and knowledge given should be at its fullest so that a patient's autonomy is at its fullest when deciding. In many of our classes, the idea of cura personalis has been instilled in us so much now that it pains me to hear that physicians are still not taking care of the whole person. In this circumstance, I can see physicians making the argument that the patient is not receiving a lesser quality of care. However, by not informing them of this at-home treatment, it can harm them in other ways. I imagine a domino effect in which financial burdens or the stresses of having to go into a clinic can generate other physiological or mental risks.

    On the same note, I found this article by Bentley, Effros, Palar, & Keeler (2008) that discusses "waste" in the US healthcare system. As we know, the cost of healthcare in the US is much higher than those in other countries with similar or better health system performance. Through a combination of health insurance and medical uncertainties, inefficient and low-value services are often encouraged. In context with the home hemodyalysis discussion, it fits perfectly into what the article discusses because HHD appears to be the more cost-effective and efficient option yet physicians are not opting to release this information. Do physicians genuinely not know about HDD or is it a secret purposefully kept hidden for greedy purposes?

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690367/

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  2. In regards to the physicians, it seems to be a combination of "greed", unfamiliarity with the procedure, and probably some simple ignorance. The article that I based my post on talked about it quite a bit, but I couldn't fit it in under the word limit. According to the author, there are quite a few nephrologists that know about HHD, but don't understand it well enough to use it as a treatment option. I'm pretty amazed by this, considering HHD has been around since the 90s, giving physicians plenty of time to learn about it. In a similar vein, I'm sure there are physicians that just don't know it's an option. Either way, I think physicians should be prepared for a lifetime of learning and self improvement, always ensuring they're using the best, most up to date procedures to treat patients. Under the principles of beneficence, non-maleficence, and justice, patients are due the best treatment possible, and should not have to request better medical procedures because their providers haven't done their homework.

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