A Change in Adequacy Standards Could
Create a Nightmare: Is It Necessary?
Molly Cahill
According
to the United States Renal Data System (USRDS) (2006) Report, 0.6% or
1,954 patients on hemodialysis receive their treatment at home. If
daily dialysis, either home hemodialysis (HHD) or peritoneal dialysis
(PD), is necessary to improve mortality, is it possible that many of
our patients on hemodialysis are under-dialyzed and that their
prescriptions are therefore inadequate? Is this malpractice? I believe
that if our treatment is based on the best available evidence based
standards, then no.
The National Kidney Foundation’s Kidney Disease Outcomes Quality
Initiative (KDOQI) is a set of literature-based practice guidelines
designed to improve the quality of life for patients on dialysis. The
Center for Medicare and Medicaid Services (CMS) policy has been altered
in response to the guidelines. Although prescription practice patterns
in the United States (U.S.) vary somewhat, standards determined by
consensus that dialysis care should deliver a Kt/V of at least 1.2
(single pool, variable volume) for an adult receiving hemodialysis. The
delivered dose using URR = 65% or the equivalent of Kt/V of 1.2. Can
anyone argue that the KDOQI standards are in fact malpractice without
evidence? Many programs already raise the minimums for adequacy within
their individual facility polices with the goal of improving patient
outcomes.
Health Care Epidemic
We
know that chronic kidney disease (CKD) is a worldwide health problem.
In the U.S., approximately 20 million Americans are thought to have
CKD. Currently, approximately 400,000 individuals are receiving renal
replacement therapy, including dialysis and kidney transplant. If 60
million Americans are thought to have diabetes, these numbers will not
get any smaller. I do not believe it is possible to maintain the
practice of prescribing daily dialysis for all. Who would pay for the
cost of care for the thousands of patients who might opt for HHD? Would
in-home daily nocturnal hemodialysis be the treatment of choice for
adequacy and, if so, who would train all of these patients? How do we
determine who is allowed to participate based on staffing? This would
create an ethical dilemma and a nightmare!
Current and Future Staffing Nightmare
Dialysis units face issues related to an aging workforce and high
turnover. All 50 states will experience the nursing shortage to some
degree by 2015. This shortage is expected to reach more than a million
nurses according to the Heath Resources and Services Administration
(2005).
Many dialysis facilities are adding nocturnal programs with varying
schedules and prescriptions from 3-5 days per week. These programs are
requiring changes that are already difficult and challenging. In
addition, the 2004 American Nephrology Nurses’ Association membership
survey reported that 19% of respondents plan to leave their jobs within
the next year (ANNA, 2005). In a national poll of health care
recruiters, the average RN turnover rate was 13.9% and the vacancy
16.1% (Bernard Hodes Group, 2005). Staff turnover creates additional
obstacles with personnel training, decreased competency with high
turnover, increased cost related to productivity, and also potentially
increases errors.
Economic Impact of Healthcare for Patients with ESRD
Medicare and Medicaid are currently the primary payers for dialysis
treatment and are essential programs that already face insufficient
resources and increasing demand. According to the USRDS 2006 Report,
the cost of the ESRD program is growing, but the cost of ESRD spending
in relation to all Medicare dollars has also increased dramatically. In
2004, Medicare spent over $19 billion dollars on the ESRD program,
accounting for more than 6% of the total Medicare budget (USRDS, 2006).
Additionally, the U.S. faces many challenges associated with healthcare
financing and Congress has limited resources to allocate.
Patient Quality of Life Considerations
Al-Arabi (2006) identified “Life Restricted” as a category of themes
during a qualitative study of patients on hemodialysis who were
describing challenges they face, including feeling tied down, left out,
and doing without. If patients’ treatments were extended or more were
trained for home hemodialysis, I believe this would add to ethical
dilemmas related to patient rights. If somehow we had the staff for the
increased time, how do we decide who dialyzes during the day and who
comes for the night shift? Would there be any accountability for the
patients for missing a treatment, with a regimen that includes more
dialysis time?
According to the USRDS, the number of patients relying on home dialysis
has declined. I believe more research is needed to support changes in
standards for adequacy that could not only improve the quality of life
for our patients with improved outcomes but also allow them to
participate in other activities that will improve their well being.
More Questions Than Answers
Diaz-Buxo and Crawford-Bonadio (2006) suggest that home dialysis is the
answer to adequacy but offer all of the same obstacles with economics,
staffing, education, and also added cultural issues. The obstacles are
large and difficult and right now we are prescribing and providing
dialysis based on what is practical for the population under the
standards that rely on the best evidence.
While dialysis and improved treatments keep most patients with kidney
disease alive far longer than just decades ago, additional research is
needed on adequacy that documents improved quality of life for those
who received daily or extended treatments in order to make changes to
the guidelines that we currently use to prescribe treatment. With the
number of patients with CKD increasing each year, I believe that
without adequate funding to strengthen and expand kidney disease
research and treatment programs, and if we do not address the current
and expected worsening nursing shortage, the nation would be unable to
ensure that all patients with CKD have access to quality and
comprehensive treatment if the standards and guidelines were changed.
The U.S. is already having problems meeting the established quality
indicators, so the issue is that, even at current standards, it is not
working. By increasing the guidelines, will we only succeed in
decreasing quality of care for all patients by attempting to improve
outcomes for the minority? HHD or PD for all is an interesting concept,
but cannot be achieved with the current nursing shortage, insufficient
funding, and some lack of accountability on the part of patients to
their treatment regimen. There is no question that increasing treatment
time would improve outcomes, but to call not doing it malpractice is
harsh and impractical.
References
Al-Arabi,
S. (2006). Quality of life: Subjective descriptions of challenges to
patients with end stage renal disease. Nephrology Nursing Journal,
33(3), 285-293.
American Nephrology Nurses’ Association. (2005). 2004 Membership survey. Pitman, NJ: Author.
Bernard Hodes Group. (2005). Nursing shortage. Retrieved April 28, 2007 from, http://www.hodes.com.
Diaz-Buxo, J.A., &
Crawford-Bonadio, T.L. (2007). Major difficulties the U.S. nephrologist
faces in providing adequate dialysis. Blood Purification, 25(1), 48-52.
Retrieved October 1, 2007, from
http://content.karger.com/ProdukteDB/produkte.asp?Aktion=Ausgabe&Ausgabe=232307&ProduktNr=223997
National Kidney
Foundation. (2006). KDOQI clinical practice guidelines and clinical
practice recommendations for 2006 updates: Hemodialysis adequacy.
American Journal of Kidney Disease, 48, S1-322.
United States Renal
Data System (USRDS). (2006). 2006 annual data report: Atlas of end
stage renal disease in the United States. Bethesda, MD. National
Institutes of Health.
United States
Department of Health and Human Services. (2005). What is behind HRSA’s
projected supply, demand, and shortage of registered nurses?
Washington, DC: Author. Retrieved October 1, 2007, from
ftp://ftp.hrsa.gov/bhpr/ workforce/behindshortage.pdf
The Controversies in Nephrology Nursing
department focuses on exploring ethical and clinical issues within the
nephrology clinic practice in a point/counterpoint format. Address
correspondence to: Christy Price Rabetoy, Department Editor, through
the ANNA National Office; East Holly Avenue/Box 56; Pitman, NJ
08071-0056; (856) 256-2320; or by emailing her at
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your comments to the Editor (see Discussion Area). The opinions and
assertions contained herein are the private views of the contributors
and do not necessarily reflect the views of the American Nephrology
Nurses' Association.
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