This is a handout I gave out to an under-grad stats class (where I was a guest lecturer) where I attempted to use a real life situation to impress upon the students the importance of statistics. I then went through six published journal articles relating to this topic to show them how to make a rational decision based on the current literature and statistics available on ESRD to show them how to come to an "evidence based" decision.
Statistics: So What?
Case Study for Kidney Failure Treatment Options Using Statistics as a Guide
Presenter: Eli Lazovsky, MPH
Date: June 14, 2011–06–14
For: HTC Statistics Class
You are advising a friend who has ESRD/Kidney Failure about his/her treatment options. What would you suggest to them as a rational course of action. Remember, there is not necessarily only 1 correct option. Be able to back up (using statistics) whatever you decide to advise your friend. Your friend isn’t so proficient in statistics so (s)he is relying on what you learned in your statistics class to help out.
What is your recommendation to your friend. Focus on what decision correlates with the following goal: Increase Life Expectancy
Diagnosis: ESRD
Treatment Options:
A. do nothing
B. dialysis
C. transplant
B. Dialysis
1. hemodialysis
2. peritoneal dialysis
Type of Access Point for the hemodialysis
1. AVF
2. AGF
3. Catheter
Frequency of Hemodialysis
1. 3 times a week
2. 6 times a week
C. Transplant
1. Before starting dialysis
2. After starting dialysis
Status of Organ Donor
1. Deceased Donor/Cadaver Organ
2. Live Donor
Type of Organ
1. Ideal Organ
2. Marginal Organ
Friday, June 17, 2011
Monday, June 6, 2011
Treatment Modalities for ESRD Patients: How to Increase Life Expectancy
A person who has kidney failure, or ESRD, should be cognizant that the choices s(he) and their physician make regarding their care will effect their life expectancy.
For example, a study comparing Dialysis treatment in Italy and the U.S. points out that in 2006, the annual mortality rate for people with ESRD in Italy was 11.2+/-.6 compared to 24% in the U.S. A link to the abstract of the article can be found here.
The authors write, in part, that "[t]he following may explain the low mortality for ESRD patients in Italy: low prevalence of diabetes, high use of AV fistulae, delivery of care by nephrologists beginning in pre-ESRD stages, their involvement in placement of dialysis vascular access, and their physical presence requirement during dialysis sessions."
Keep in mind, as of 2006, only 38.6% of dialysis patients had AV fistulas compared to approximately 82% of dialysis patients in Italy (figures taken from the study cited above). Recent data is much more encouraging. As of December 2010, in the U.S., 57.5% of hemodialysis patients had AV Fistulas. See here.
AV fistulas are associated with lower infection rates compare to people with AV grafts and thus better long term outcomes for the patient.
A Veterans Administration study linked to here also found that people on hemodialysis who had AV fistulas lived on average about 3 months longer compared to people with AV grafts.
The bottom line is by studying the various manners of treatment for ESRD both domestically and internationally, ESRD best-practices guidelines can be fashioned to increase the life expectancy and the quality of life for people on dialysis.
For example, a study comparing Dialysis treatment in Italy and the U.S. points out that in 2006, the annual mortality rate for people with ESRD in Italy was 11.2+/-.6 compared to 24% in the U.S. A link to the abstract of the article can be found here.
The authors write, in part, that "[t]he following may explain the low mortality for ESRD patients in Italy: low prevalence of diabetes, high use of AV fistulae, delivery of care by nephrologists beginning in pre-ESRD stages, their involvement in placement of dialysis vascular access, and their physical presence requirement during dialysis sessions."
Keep in mind, as of 2006, only 38.6% of dialysis patients had AV fistulas compared to approximately 82% of dialysis patients in Italy (figures taken from the study cited above). Recent data is much more encouraging. As of December 2010, in the U.S., 57.5% of hemodialysis patients had AV Fistulas. See here.
AV fistulas are associated with lower infection rates compare to people with AV grafts and thus better long term outcomes for the patient.
A Veterans Administration study linked to here also found that people on hemodialysis who had AV fistulas lived on average about 3 months longer compared to people with AV grafts.
The bottom line is by studying the various manners of treatment for ESRD both domestically and internationally, ESRD best-practices guidelines can be fashioned to increase the life expectancy and the quality of life for people on dialysis.
Monday, May 16, 2011
Why Doesn't the Kidney Transplant Waiting List Reflect the Missing 500,000?
This is a follow-up to the last post found here.
I think there are several possible components which together combine to give at least a partial explanation as to where are the missing 500,000 people with ESRD who are not on the kidney-transplant-waiting-list.
I think that a critical but correctable component of the problem is that the supply of kidneys that become available annually are so miniscule compared to the demand for kidneys, that patients and their physicians often face the grim reality that (under the current manner in which UNOS appropriates organs) their chances of obtaining a kidney are so slight that they make the sad (but often economically rational decision) not to undergo the financial, physical, and emotional burden and trauma of living with the constant anxiety of waiting for an organ that may never come so they just fore-go the process altogether and survive on maintenance dialysis.
This problem can be at least partially ameliorated by expanding the supply of kidneys available for transplantation - like by increasing the supply of live donors! (Another more long term approach to the problem is to screen high risk populations for high blood pressure [like African Americans, people with diabetes, etv.] before they present with symptoms of ESRD so that their blood pressures can be controlled and their kidneys continue to function at an acceptable level. This would decrease the amount of kidneys demanded on the transplant list.)
Some other components that may explain the missing 500,000 people from the kidney transplant waiting list may include:
1. Some people are so sick they would probably never live through the procedure so they don't bother trying to get on the waiting list.
2. Geographically, some people are very distant from a transplant center so they might not be able to get to the transplant center in time to get the organ so they don't bother signing up (but keep in mind that the time sensitive component of transplantation goes away with live-donor-donations).
3. Some people cannot afford the costs involved in the transplant. For instance, they might be denied a spot on the transplant list if the transplant center thinks they may not be able to afford the anti-rejection medication needed to elongate the lifespan of the organ.
I think there are several possible components which together combine to give at least a partial explanation as to where are the missing 500,000 people with ESRD who are not on the kidney-transplant-waiting-list.
I think that a critical but correctable component of the problem is that the supply of kidneys that become available annually are so miniscule compared to the demand for kidneys, that patients and their physicians often face the grim reality that (under the current manner in which UNOS appropriates organs) their chances of obtaining a kidney are so slight that they make the sad (but often economically rational decision) not to undergo the financial, physical, and emotional burden and trauma of living with the constant anxiety of waiting for an organ that may never come so they just fore-go the process altogether and survive on maintenance dialysis.
This problem can be at least partially ameliorated by expanding the supply of kidneys available for transplantation - like by increasing the supply of live donors! (Another more long term approach to the problem is to screen high risk populations for high blood pressure [like African Americans, people with diabetes, etv.] before they present with symptoms of ESRD so that their blood pressures can be controlled and their kidneys continue to function at an acceptable level. This would decrease the amount of kidneys demanded on the transplant list.)
Some other components that may explain the missing 500,000 people from the kidney transplant waiting list may include:
1. Some people are so sick they would probably never live through the procedure so they don't bother trying to get on the waiting list.
2. Geographically, some people are very distant from a transplant center so they might not be able to get to the transplant center in time to get the organ so they don't bother signing up (but keep in mind that the time sensitive component of transplantation goes away with live-donor-donations).
3. Some people cannot afford the costs involved in the transplant. For instance, they might be denied a spot on the transplant list if the transplant center thinks they may not be able to afford the anti-rejection medication needed to elongate the lifespan of the organ.
Tuesday, May 3, 2011
The Missing 500,000 People: How Many People Could Benefit from Kidney Transplants?
Does any one know how many people can actually benefit from a kidney transplant in the U.S.? I'm sorry to say, the answer is no! There is an exact number of people registered on the waiting list, but if you are not registered on the list (if for example, you cannot find a transplant center willing to accept you) you are not counted even though you may desperately need a transplant to elongate your life!
Often, a problem cannot be dealt with appropriately until the problem is identified and the scope of the problem understood. There is a severe shortage of organs available for transplantation in general. I will only deal with the acute shortage of kidneys for the time being.
According to the OPTN, or Organ Procurement and Transplantation Network (which is affiliated with the the DHHS, or the Department of Health and Human Service's HRSA, or Health Resources and Services Administration) there are only 88,392 individuals awaiting a kidney transplant on their waiting list. (Accessed from http://optn.transplant.hrsa.gov/latestData/rptData.asp
based on OPTN data as of April 29, 2011)
According to the USRDS, or the United States Renal Data System, as of 6/30/2010 there were 591,642 people in the U.S. with ESRD. See here
That means there are over 500,000 people with ESRD who are not on the kidney transplant waiting list!!! Most of these people are on dialysis to keep them alive.
People who receive transplants live substantially longer than those on dialysis.
See here for more specific data on the subject.
So why doesn't the kidney transplant waiting list more accurately reflect the number of people who could benefit from transplants?
I'll try to partially answer that in another post.
Often, a problem cannot be dealt with appropriately until the problem is identified and the scope of the problem understood. There is a severe shortage of organs available for transplantation in general. I will only deal with the acute shortage of kidneys for the time being.
According to the OPTN, or Organ Procurement and Transplantation Network (which is affiliated with the the DHHS, or the Department of Health and Human Service's HRSA, or Health Resources and Services Administration) there are only 88,392 individuals awaiting a kidney transplant on their waiting list. (Accessed from http://optn.transplant.hrsa.gov/latestData/rptData.asp
based on OPTN data as of April 29, 2011)
According to the USRDS, or the United States Renal Data System, as of 6/30/2010 there were 591,642 people in the U.S. with ESRD. See here
That means there are over 500,000 people with ESRD who are not on the kidney transplant waiting list!!! Most of these people are on dialysis to keep them alive.
People who receive transplants live substantially longer than those on dialysis.
See here for more specific data on the subject.
So why doesn't the kidney transplant waiting list more accurately reflect the number of people who could benefit from transplants?
I'll try to partially answer that in another post.
Wednesday, April 13, 2011
Follow Up: Arizona Restores Medicaid Coverage for Transplants
Reuters is reporting here that Arizona has restored funds to its state Medicaid program so that it will once again cover organ transplantation once again. See one of my previous posts here where I vociferously attacked the cuts and the humanity of all involved in letting a lady die as a result of the cuts.
Its good to see that the people of Arizona (as reflected by the action taken by their elected representatives) have taken appropriate action to rectify an unconscionable piece of legislation which was resulting in the deaths of citizens of Arizona.
Again, this was not only a government-made disaster, but it was also a man-made disaster on many levels including the family, community, and medical field levels.
I dare to hope that there were some hospitals which performed transplants as charity care during the time when there was no Medicaid coverage. But I'd love to actually see some proof of that.
Its good to see that the people of Arizona (as reflected by the action taken by their elected representatives) have taken appropriate action to rectify an unconscionable piece of legislation which was resulting in the deaths of citizens of Arizona.
Again, this was not only a government-made disaster, but it was also a man-made disaster on many levels including the family, community, and medical field levels.
I dare to hope that there were some hospitals which performed transplants as charity care during the time when there was no Medicaid coverage. But I'd love to actually see some proof of that.
Sunday, April 3, 2011
NYTimes Explores Dialysis: At What Cost Do We Keep People Alive
See this interesting (though slanted) article about dialysis, governmental policies which cover the cost of ESRD, and end stage renal disease (which includes dialysis treatment), and the NYTimes's slant that people who are very sick and very expensive to treat may be better off dying than going on dialysis (remind anyone of death panels?).
The NYTimes does do thoughtful readers and listeners a service by allowing dialysis patients to describe their lives in their own words. Listen here.
The bottom line is this - irregardless of what the NYTimes thinks. People living with ESRD, their doctors, and the stakeholders who pay for the treatment (like Medicare, insurance companies, and Corporate Self-Insurance health plans) should insist on the highest quality evidenced based standard of care for ESRD treatment which includes dialysis treatment. If this standard of care is applied, people with ESRD can live longer and costs can be contained.
The NYTimes does do thoughtful readers and listeners a service by allowing dialysis patients to describe their lives in their own words. Listen here.
The bottom line is this - irregardless of what the NYTimes thinks. People living with ESRD, their doctors, and the stakeholders who pay for the treatment (like Medicare, insurance companies, and Corporate Self-Insurance health plans) should insist on the highest quality evidenced based standard of care for ESRD treatment which includes dialysis treatment. If this standard of care is applied, people with ESRD can live longer and costs can be contained.
Thursday, March 24, 2011
Confronting the Intrenched Organ Donation System: It is possible
Below are examples of some blogs, websites, and articles which all confront the reality of the current (possibly semi-dysfunctional) organ transplant disbursement system and attempt to shine light on it, study it, and offer ways to improve it. Or, they break with the current system altogether and blaze alternative paths to increase the supply of organs available for transplantation.
I don't attest to the veracity of the claims made in these links. Make your own judgment. But the current system can most assuredly be improved. It will take people and organizations similar to those linked to below who aspire to improve the current system to create the change necessary which will lay the foundation to increase the supply of organs and thereby save lives.
For a live kidney donor recipient's personal outlook on the entrenched interests opposing live-donor donation see this website.
For a blog about alternative methods to increase the supply of organs available for transplantation see here.
For a website that attempts to link live organ donors with people in need of a transplant see this website.
For a press release about a grant awarded to study the outdated organ disbursement method and how it causes unequal access to donated organs based on where a person live see here . Also see here for an old post on the issue where I propose a study designed partly to determine the effect of a person's distance to a transplant center and the time it takes for the person to receive an organ. Yes, its a very technically worded post so don't say I didn't warn you.
And finally, see this link for a book titled, "The U.S.Organ Procurement System" where the authors, David L. Kaserman and A.H. Barnett engage in a thorough economic analysis of current U.S. organ transplant policy, the problems with it, and a proposal explaining how organ markets would operate in a manner which would save lives by increasing the supply of organs available.
I don't attest to the veracity of the claims made in these links. Make your own judgment. But the current system can most assuredly be improved. It will take people and organizations similar to those linked to below who aspire to improve the current system to create the change necessary which will lay the foundation to increase the supply of organs and thereby save lives.
For a live kidney donor recipient's personal outlook on the entrenched interests opposing live-donor donation see this website.
For a blog about alternative methods to increase the supply of organs available for transplantation see here.
For a website that attempts to link live organ donors with people in need of a transplant see this website.
For a press release about a grant awarded to study the outdated organ disbursement method and how it causes unequal access to donated organs based on where a person live see here . Also see here for an old post on the issue where I propose a study designed partly to determine the effect of a person's distance to a transplant center and the time it takes for the person to receive an organ. Yes, its a very technically worded post so don't say I didn't warn you.
And finally, see this link for a book titled, "The U.S.Organ Procurement System" where the authors, David L. Kaserman and A.H. Barnett engage in a thorough economic analysis of current U.S. organ transplant policy, the problems with it, and a proposal explaining how organ markets would operate in a manner which would save lives by increasing the supply of organs available.
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