Cheaper at-home dialysis gaining popularity

Tanya Christie was one of the first patients I cared for after I finished training as a kidney specialist.

Faced with end-stage kidney disease and the prospect of going on dialysis, Tanya, 50, of Philadelphia, was one of the few patients who educated herself and chose a lesser-known treatment - peritoneal dialysis (PD) - which can be done at home.

PD is cheaper, more convenient, and gets better results than the typical dialysis clinic, yet few American patients choose it or even know about it. To me, Tanya's successful care with PD exemplifies its advantages and suggests a path that more patients should consider.

Peritoneal dialysis uses an internal membrane in the patient's belly to remove toxins. It was introduced in the United States in the mid-1970s, and its success relies on aggressive education, patient involvement, strong nursing support, and physician mentorship.

It stands in contrast to "in-center" hemodialysis (HD), in which patients get dialyzed three times a week in a clinic. With PD, patients perform dialysis at home under the supervision of nurses, who are the backbone of this type of program.

As Tanya puts it: "The tag 'dialysis patient' has an insidious way of eroding into all that came before in one's life. People treat you like an eggshell, hesitant to believe that life can go on. The most fulfilling aspect of PD is being able to show everyone that being on dialysis and a normal life can coexist."

Her views resonate internationally. In Hong Kong, Japan, Australia, New Zealand, and Mexico, PD is a dominant mode of dialysis.

These countries have achieved excellent patient outcomes at lower costs. Hong Kong's "PD-First" is the prototype, mandating home dialysis as the treatment of choice, unless it is not feasible.

So 80 percent of dialysis patients in Hong Kong are on PD, at a cost about 40 percent that of in-center hemodialysis ($13,000 for PD vs. $30,000 for HD a year). With patient survival rates about 75 percent at eight years, their outcomes on PD remain unsurpassed.

Medicare also could save big money on PD. Its costs for PD vs. hemodialysis were $66,751 and $87,561 per patient in 2010, serving about 500,000 patients total.

The U.S. health system is on an unsustainable path, and kidney disease is a big reason. Medicare spending in that area rose by 8 percent to $33 billion in 2010, accounting for 6.3 percent of the vast program's budget.

Sadly, all this spending mania on hemodialysis creates average outcomes at best.

Fewer than 8 percent of American dialysis patients are on PD despite its clear cost-effectiveness, high patient satisfaction, and excellent outcomes.

A national PD expert, Rajnish Mehrotra, professor of medicine at the University of Washington, says, "PD in the United States is not a mainstream therapy; most practicing nephrologists and dialysis facilities don't even offer PD as a therapy." It is not surprising, then, that most patients are unaware of PD as an option, and many nephrologists lack the experience and, hence, competence, in providing care for PD patients. It is often an "afterthought."

Two factors explain this. First, years ago, financial incentives existed against the use of PD. So, providers didn't invest enough in the field. Second, a perception persists that PD is inferior.

That is a myth. The only major risk is infection of the PD catheter that enters the abdomen. With proper education and technique, this risk can be cut close to zero. Even developing countries, where sanitation can be spotty, have had good outcomes.

Now, finally, the number of patients on PD is poised to grow. The government just announced 12 percent cuts in bundled costs for hemodialysis, creating more incentives for lower-cost PD. The Affordable Care Act also will attract many new PD patients, but only if physicians and practices get past the old myths about home therapy.

Dialysis patients deserve the best. It is also time to rein in the mushrooming costs of dialysis.

As Tanya Christie put it: "PD allowed me to embrace dialysis and make it a part of my life, instead of turning it inside out."