Individuals Are Selecting Kidney Dialysis at H

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People Are Choosing Kidney Dialysis at H

In January there might be a lot more people like Mary Prochaska.

Ms. Prochaska, 73, a retired social worker in Chapel Hill, NC, has advanced chronic kidney disease and is on dialysis to filter waste from her blood while she waits for a kidney transplant, her second. But she no longer visits a dialysis center three times a week, the standard treatment. There, nurses and technicians monitored her for four hours while a machine cleaned her blood.

Instead, she chose dialysis at home. "It's easier for your body and better for your health," she said. "And far better than exposing yourself to what you get from a group of people," during a pandemic at a center.

With the help of her husband, Ms. Prochaska performs peritoneal dialysis. After a surgeon implants a tube in her side, her abdominal wall acts as a filter. After a few weeks of exercising, she started using a home machine called a cycler to remove excess fluids and debris.

"It automatically pumps in and out five times a night while you sleep," she said. "When you get up, you're done. It's like a normal life."

So far, her only unpleasant side effect has been fatigue, which sometimes requires afternoon rest. A company called TruBlu Logistics supplies the cases of solutions, tubing, and other consumables, and Medicare pays the costs, which are significantly lower than in-center dialysis.

According to the United States Renal Data System, 14.5 percent of Medicare beneficiaries had chronic kidney disease in 2017, which rose sharply with age from 10.5 percent of 65-74 year olds to nearly a quarter of those over 85 . Almost half of the dialysis patients were older than 65.

For decades, health care lawyers and many nephrologists have encouraged more patients to consider home dialysis. That year, of 124,500 patients newly diagnosed with advanced kidney disease (also known as end-stage kidney disease), only 10 percent started peritoneal dialysis like Ms. Prochaska.

Another 2 percent turned to home hemodialysis and removed waste with machines adapted to those used in centers.

Everyone else who started dialysis went to a dialysis center likely owned by one of the two companies that dominate the industry, DaVita or Fresenius.

However, this fall, Medicare announced a mandatory program to transform that system that will cover about 30 percent of beneficiaries with advanced chronic kidney disease and include nearly 400,000 people. Starting January 1, payment bonuses – and later penalties – will be used to increase the proportion of patients using home dialysis and receiving transplants.

Even experts who don't love outbound administration have cited this approach as the biggest change for kidney patients since 1972, when Richard M. Nixon signed a bill providing Medicare coverage for patients with kidney failure regardless of age.

"That's brave," said Richard Knight, transplant recipient and president of the American Association of Kidney Patients. "There are many incentives for providers to do things that they traditionally haven't done."

"I think it's going to have a really profound impact on kidney care," said Dr. Abhijit Kshirsagar, nephrologist and director of the dialysis program at the University of North Carolina.

Studies have shown that home dialysis patients have a greater sense of independence and autonomy with more flexible schedules that make work or travel easier. You experience a better quality of life. Why do so few choose it?

Some patients start dialysis when they are taken to an emergency room due to a health crisis. With little time to explore the decision or get the training necessary to dialyze at home, they end up in centers.

But many don't seem to know that they have alternatives. In a 2016 study, almost half of patients who received hemodialysis at the center said it was not their choice.

"There are patients who don't know they can dialysis at home," said Dr. Suzanne Watnick, chief physician at Northwest Kidney Centers in Seattle. "For me this is a travesty. Patients who have been informed about the various modalities have a significantly higher participation rate in home dialysis."

But the training doctors receive cannot emphasize this option. Once patients get used to a center "where everything is done for you, you likely won't take the responsibility of doing it at home," Knight said. Home dialysis can be daunting or frightening, and neither doctor's offices nor nonprofit centers have had much motivation, at least financially, to promote it.

Thirty percent of them will soon. Medicare increases its monthly payments for each patient on home dialysis from 3 percent in the first year and decreases thereafter. In practices and dialysis clinics, reimbursements are adjusted up or down depending on the overall rate of home dialysis and transplantation.

Several new voluntary programs will also create incentives. Beginning April, Medicare will pay providers a $ 15,000 bonus over a three-year period if a patient receives a successful kidney transplant. Another measure provides greater support for living kidney donors.

It remains to be seen whether such incentives significantly increase dialysis and transplantation at home.

Some vendors who find the penalties might outweigh the bonuses are reluctant to fall into the 30 percent of Covered Practices or Centers that are randomly assigned by zip code. "The average nephrologist is going to have a cut in wages," said Dr. Watnick.

In addition, not all elderly kidney patients can or will not dialyze at home. "You may have some degree of cognitive impairment" or be too fragile to lift bags of solution, said Dr. Gerald Hladik, chief of nephrology at the University of North Carolina. You need space for supplies and a clean, private dialysis room.

Even with detailed discussion and clarification, it is unclear which proportion could ultimately decide in favor of home dialysis. Maybe 25 to 50 percent, suggested Dr. Watnick before – "but we don't know."

Although the new Medicare model excludes nursing home residents and people with dementia, the choice is otherwise up to the patient. Especially during a pandemic, "we advocate patients having the choice to go home," Knight said. "But not for pushing people home."

Some older people with multiple illnesses may have no dialysis at all. Wherever it is done, it is physically and mentally stressful and survival decreases with age.

Dr. For example, Hladik's 75-year-old father wanted to spend the rest of the days at home with his dog or on the beach. He chose conservative management to control his symptoms and lived without dialysis for a year and a half.

But home dialysis worked well for Jorge Moreira, 65, an accountant in Burien, Was. Four years ago, as his kidney disease progressed, he began dialysis at a Northwest Kidney Centers clinic.

He found it difficult to arrive at 5:30 a.m. three days a week so he could be ready and go to his office by 9:30 a.m., and suffered from painful leg cramps. A technician suggested looking into peritoneal dialysis. his doctors agreed.

The first few months were difficult, said Mr Moreira as he learned the manual technique and dialyzed four times a day. Then he completed a bicycle machine like Ms. Prochaska and now swaps fluids overnight. It's easier, he said, and suits his active life. He walks and rides mountain bikes and serves as a pastor.

"I have more time for myself, my family, my business," he said. “I have more strength. I sleep very well, I feel good. "

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