ESRD Stats in Focus:Prevalence, Annual Number of Kidney Transplants, Costs Per Patient, and Patient Survival Rates

ESRD Prevalence and Prevalent Rate

• At the end of 2009, more than 871,000 people were being treated for ESRD.
• Between 1980 and 2009, the prevalent rate for ESRD increased nearly 600 percent, from 290 to 1,738 cases per million.

Kidney Transplantation

After rising steadily from 1980 to 2006, the annual number of kidney transplants declined in 2007 and 2008.

Costs per Patient

• ESRD annual expenditures per patient have increased slightly in recent years.
• From 2006 to 2007, transplant costs per patient decreased but increased again in 2008.
• Yearly costs for treating a patient on HD are nearly triple the costs for treating a transplant patient.

Patient Survival Rates for Dialysis and Transplant Patients

At 85.5 percent, the 5-year survival rate for transplant patients is more than twice the 35.8 percent survival rate for dialysis patients.











Special thanks to the

National Kidney and Urologic Diseases
Information Clearinghouse (NKUDIC)

and the

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

 for the graphs which were taken from

http://kidney.niddk.nih.gov/kudiseases/pubs/kustats/

 on 8/16/12.

Random Thoughts on Innovation: Application to Healthcare: Inspiration Based on the Life of Rav Chaim Brisker: Post from Toronto's Pearson Int'l Airport

I often feel a bit let down when people accept the status quo or the orthodoxy of any given field. Each and every thinking person should analyze for themselves if things are being done in the best possible manner to induce the best possible results. Humans are inherently imperfect so obviously the actions which humans take are merely reflections of themselves and are thus sometimes going to be imperfect.
I want to now depart from a direct discussion about healthcare for a moment to bring out an idea about a philosophy about life (to which I zealously subscribe).
I have had the very lucky merit to have been a student of Rabbi Ahron Soloveichik before he passed away and continue to merit to be a student of his son Rav Moshe Soloveichik. Many people have fine teachers, mentors, clergy, and leaders. What is so special about these two giants among men? They continue in the glorious path of their illustrious progenitor Rav Chaim Soloveichik who was the Chief Rabbi of  Brisk in Lithuania. So what was so unique about Rav Chaim?
When a person analyzes any problem, they can be overwhelmed by the apparent challenges, contradictions, and roadblocks presented by the obstacle and they can be overwhelmed and become dispirited and give up on attempting to solve the given challenge...or, even worse, a person may not even attempt to solve the problem. They can become slaves to the status quo.
 Rav Chaim brought to the world of Torah scholarship in particular, (as well as to the world of acts of chesed or loving kindness more generally) a new brazen weltanschauung that every problem can be solved with a deep analysis of the given texts of Talmud or passages of Maimonides (or social ills) and therefore harmony can be created from apparent contradiction and chaos. He rejected the status quo and strove to attempt to mold the world into a more perfect state (by decreasing the number of apparent contradictions which exist) by being the innovator par excellance.
 Rav Chaim applied his innovative approach to the sphere of acts of loving kindness as well. One such example is from well known occurrences in Brisk where Jewish and even non-Jewish young mothers who had their children out of wedlock would drop their babies at Rav Chaim's doorstep at all hours of the night and that he would arrange for the best care for these babies and he would continue to look after them until they were married off.
Rav Chaim didn't see problems. He didn't see challenges. Instead of focusing on the problems and challenges of every social situation or Rabbinic textual difficulty, Rav Chaim would focus on the solution to the problem. Now, Rav Chaim wasn't naive. With his great and legendary power of incisive analysis, he understood how difficult it would be to raise children born out of wedlock (especially in those days when there was certainly a much stronger stigma attached to these children). He understood that there had been apparent contradictions in Maimonides that scholars had struggled to understand for 800 years.
But Rav Chaim understood that to solve problems you cannot be constrained by the past, by social pressure, or by the accepted norms of the intelligentsia of the era. In fact, when Rav Chaim was innovating his new approach of textual analysis, he was often scorned and derided by the "old-guard" of Rabbinic leadership who derided him as "the chemist." Basically, Rav Chaim applied the logic of the scientific method to Torah learning. If you have two phenomenon with apparently the same inputs but you obtain two different outputs, logic told Rav Chaim that obviously you don't have the same inputs as you originally thought. So Rav Chaim labored to analyze, and, if he was successful, he was able to detect the differences between the two inputs.  While it might have appeared at first glance that the 2 cases had the same inputs, Rav Chaim with the precision akin to that of the precision needed by a neurosurgeon, was able to realize the differences and answer the apparent contradictions. If 2 given passages of Maimonides or Talmud contradicted themselves, or if Maimonides apparently contradicted the Talmud (which is theoretically impossible because Maimonides codified and organized the various halahkhic (AKA Jewish Law) holdings and precedents of the Talmud), Rav Chaim would read the texts extraordinarily closely to discern which passage had an extra phrase or was missing a certain passage to harmonize the apparent contradictions.
 Rav Chaim saw that which everyone thought wasn't there. It took tremendous fortitude to change the style of Torah learning. Rav Chaim innovated. He applied the logic of the scientific method to Torah study. Rav Chaim had such a strong belief in the inherent harmony of the Torah,the Talmud, and of Maimonides'es writings, that he was able to "solve" contradictions that had been unexplained or poorly explained for around 1400 years from when the Talmud was finished being organized.

Implications for healthcare policy:
 Constant experimentation, questioning of "accepting truths", insistence on comparative effectiveness research not just for the entire populations but for as many unique sub-populations as possible, which interventions lead to actual provable increased life expectancy and quality of life, etc.
Don't forget, surgeons though until not very long ago (~70 years) that a heart should never be cut into....the dictum of "don't touch the heart." There was nothing wrong with this approach...this was true for the level of medical technology and progress that existed at that time. But it wasn't an immutable law. It was an accepted norm based on the reality at that time. Times change. Innovation spreads. Medical progress marches on. Alfred Blalock and Vivien Thomas at Johns Hopkins dared to think differently about the dictum of "don't touch the heart." Since then, millions of heart procedures have been done in the world saving countless lives of humans of every age, creed, and color.
There are always manners to improve the world in general and the healthcare environment (both the clinical and financial aspects) in particular. Do we accept the imperfect status quo or do we strive to innovate and improve the healthcare environment? The legendary example of Rav Chaim Brisker instructs us how to proceed.
To be continued...

Main Principles of Increasing ESRD Life Expectancy, In Formation

 Theses are some ways to increase life expectancy in people with ESRD:
In no specific order...
1. Increase AV fistula use.
2. More frequent hemodialysis 
3. Increase pool of organs available for transplantation
a. Expand usage of expanded criteria donor (ECD) organs. Many kidneys currently not being used for transplantation may not be ideal but they will increase ESRD patients life expectancies compared to remaining on dialysis so it is a no brainer from a humanistic perspective or from a utilitarian perspective or from a rational decision making model based on probability. So why are so many kidneys being thrown away?
b. increase live donor pool
         i. increase live donation from family and community
         ii. incentivizing live donors with monetary and other means (repeal parts of the killer legislation AKA National Organ Transplant Act.) I don't like complimenting Iran, but they have a real functioning  market for kidney sales where buyers and sellers can transact business and a kidney can be bought and sold for a government mandated price of approximately $2,000 (as of a few years ago that was the price.)
4. Medicare should cover anti-rejection meds for life after transplantation. This will elongate the survival of the transplanted graft which will keep people healthier and alive. Currently, anti-rejection meds are only covered for 3 years after transplantation so if a person cannot afford the anti-rejection meds, some transplant centers won't even allow the person to receive the transplant! In some other circumstances, the person undergoes transplantation, then after they can no longer afford the meds, their bodies eventually reject the graft and then the person ends back on dialysis and Medicare will pay for that for life.....which is much more expensive and is only a treatment and not a cure which the transplanted kidneys (actually) are for as long as they do continue to function.
        To be continued...

Outrageous Care and Incompetence at the VA (Veterans Administration) Outpatient Clinic

I don't intent to appear to be picking on the VA's medical care but I really can't help myself at this point from writing about (against) a medical system that is in need of a complete rebuilding...not just some improvements at the margins. I have seen good and bad at the VA during the last 5 years but recently I have witnessed or been told about such egregious occurrences that I feel the need to dedicate another post to the VA. See last week's article here. 
For the past month or so, my friend's father, who just turned 90, has been declining precipitously. His father used to go the health club at least 3 times a week and the last month he was completely lethargic and only wanted to stay home. My friend told me last Saturday that his father was entering a new and difficult health stage and I told him although it is possible to quickly decline, I tended to doubt that there wasn't an underlying cause to his decline. I told my friend to have his father checked out for a urinary tract infection (UTI) (or other possible infections) because I remembered that his father had become lethargic a few previous times and it ended up he had UTI's.  He told me that he doesn't need to have his father checked out because he had brought  his father to the VA to see his physician on June 22, 2012. I told him that he better check it out anyways because the infection could have come right after the lab work was done or that the VA is incompetent and they forgot to let him know that there is a problem.
My friend contacted his dad's non-VA physician who took a urine specimen. Low and behold, it showed that his father has a UTI and he is now on an antibiotic and his energy level is beginning to rebound.
Then, this afternoon, his father's VA doctor called with results from the June 22 appointment (4 weeks ago) and the doctor tells him that his father had a UTI. My friend told the doctor that he already knows about it and his father is being treated. This specific healthcare provider at the VA is extraordinarily negligent. But is this incident an anomaly at the VA or a pattern...I am beginning to think it is a pattern. My friend's father suffered needlessly for an extra 3 and a 1/2 weeks.
People love throwing around buzzwords relating to healthcare like Accountable Care Organizations (ACO's) and continuity of care.
 President Obama, you already control the VA Medical System. Is this system to be revered and glorified? Practice what you preach. Add real accountability into your healthcare organization, not just some joke government plan which makes it look like there is accountability while veterans are being treated with negligence and an overall lackadaisical attitude.
If not, maybe the government should look into closing VA medical centers and allowing veterans to go to the healthcare provider of their choosing by issuing them Medicare type cards which will allow healthcare providers to be reimbursed for treating veterans similar to the manner in which they are reimbursed for seeing senior citizens.

Physician's Dilemna: Pro-active Patient Management or Reactive Treatment Only

In my last post, I discussed some of Mr. G's experiences with the VA. See here.
Mr. G's main problem was that he had stopped taking his medications. FYI, Mr. G gets his medications shipped to him from the VA for only a few dollars per prescription. The VA has an EMR (electronic medical record) of when the last time he reordered his prescriptions. His GP was able to see he had not reordered his prescriptions for some time. (When I went into his apartment to do an intervention in ~February 2012, he had a prescription which had expired in 2008! Needless to say, I threw out all of his expired meds and had to schlep to the West Side VA Hospital to pick up all of his meds so that he would begin his blood pressure meds immediately. Reminder, his blood pressure was ~200/130.)

Medical adherence/medical compliance (meaning does the patient follow the physician's advice)  is a field where a lot of important research needs to be done to determine how to enable patients to better follow their physician's advice so that hopefully they will be able to lead healthier and longer lives. Once more is understood about the interaction between the physician and the patient, and how the physicians can best convey the information to different types of patients (i.e. visual learners vs. audatory learners vs. kinesthetic learners),best practices in the field of doctor patient communication could hopefully be quickly diffused throughout the medical profession. On the most basic level, an after visit summary is a piece of paper which tells the patient what happened to them and what are they supposed to do when they go home. I assume this increases medical adherence to a certain extent.

But back to Mr G. The VA's EMR system showed that it had been a really, really long time since Mr. G had reordered his medications. Does the VA's EMR system have built in alerts to let his GP know that Mr. G is overdue in ordering his meds? Does Mr. G's GP notice while he examines Mr. G and looks at the computer that he has not reordered his meds? Or is it completely the patients responsibility to reorder his meds and the physician should take a laissez-faire approach to whether their patients are ordering their meds? Or does it depend on the sophistication of the patient...meaning that regarding a patient who is of sound mind the doc should take a hands-off approach towards medical adherence but regarding an elderly patient with the beginnings of dementia, the doc should take a proactive approach in assuring the patient's medical adherence.

Finally, since shortly after Mr. G's sky high blood pressure incident, the VA sends a nurse once or twice a week to lay out his pills in a pill container and check to make sure all of the boxes are empty (so that it can be assumed he actually took the meds and didn't discard them in some other manner.) Also, she takes his blood pressure to ascertain whether his bp is in check so that it can be assumed with more evidence to back it up that he really has swallowed his pills. (Personally, I benefit from this practice because the first few weeks after the incident I needed to lay out his pills and go upstairs to his apartment every day to make sure he really took his meds. Now, Kate, the nurse does everything.)
It is possible the VA will eventually stop sending the nurse at some point (to save money) like it stopped sending the therapist at a certain point.
 I think an interesting study the VA can do is to enroll patients in automatic prescription ordering (like Walgreens has) so that their patients always have their meds and determine if this increases those patients medical adherence to taking their meds. Another study the VA can do is whether sending the patients meds already laid out in the weekly pill containers will improve medical adherence because I can attest to the fact that Mr. G cannot lay out his pills correctly so even of the VA would automatically send the meds, I doubt he would end up taking them correctly.

Healthcare Rationing: 3 Months for a Pair of Glasses at the VA? Implications for Obamacare

Healthcare rationing, whether on the supply side (i.e.shortage of specialists or MRI machines) or on the delivery side (i.e. like when the U.S.S.R. would give their elderly populations placebos and not "waste" money on them or when in the U.S., until a few years ago, Medicare would  refuse to pay for (or ration) preventative care) needs to be carefully scrutinized and its ethical implications fully understood.
Whatever your view of Obamacare, I want to report a story that occurred yesterday at one of the VA Hospitals here in Chicago, Illinois.
 For the past several years, I take an elderly gentlemen, Mr. G, to the VA hospital for his various appointments...including to his GP who monitors his general health, and to the Vascular Surgery Clinic who monitor his aortic aneurism (it sometimes is frustrating to deal with the vascular surgeons because every time we go we see a different resident or fellow who is evaluating the case for the first time...so much for continuity of care.)  FYI, 2-4 hour waits at the Vascular Surgery Clinic is the norm, not the exception. Quite frustrating! Also, it frequently takes a relatively long time to receive appointments with specialists even when there is a medical necessity.   
In late March or early April he had an eye exam and ordered his new eye-glasses. Those glasses were finally ready this week...over 3 months later. We went yesterday to pick them up. The waiting area was overcrowded with people waiting with much patience for their turn to see the opticians. I sat on the floor due to the overcrowding. Yes, the glasses were very cheap but that is only true if your time has no value and you can live 3 months without your new glasses.
Why can't the VA use a system like the Medicare reimbursement system and allow veterans to go to any optitian, dietican, physician, etc. and just reimburse the practitioners...that way we can chose to go an optician who can deliver the eye-glasses in less than 3 months.
And, more importantly, we can choose to go the Vascular Surgeon of our preference and have one physician following the case over an extended time period.

And now for the good that occurs at the VA...This elderly gentlemen. Mr. G, was declining precipitously a few months ago. His bp was 200 over 140, he was dizzy, filling up with water, having trouble seeing, falling down, and becoming more and more incoherent. His GP, Dr. Caprio, (who just finished up his residency and who we are sorry to lose because he really cared about Mr. G) pulled out all of the resources of the VA to keep him in his own apartment and out of a nursing home (which would be tremendously more expensive to Medicaid or to the VA, whoever would have ended up paying for it.). He ordered a visiting nurse 1-2 times a week and a visiting occupational therapist 1-2 times a week. I contacted the Council for the Jewish Elderly (CJE) who now drop off 5 meals a week and send in a lady who cleans his apartment, does his laundry, and does his chores for him.

The bottom line is this....does the VA offer some good services? Yes. Could a non-VA physician have organized a visiting nurse? Yes. Would Medicare have paid for it? Most probably yes.

I just don't see why veterans cannot receive services under a health plan styled after Medicare  and  the government can eliminate almost all copays and make the coverage for Veterans even more generous and not age dependent. I also think that veterans would probably receive speedier service and would be able to go to any physician who accepts Medicare and they would not have to schlep out to the VA Hospital for every appointment.

Implications for the implementation and operationalization of the amorphous healthcare bill known as Obamacare? Draw your own conclusions.
I guess at least we are not being forced into VA style healthcare. Yet.

Which Type of ESRD Treatment Modality Correlates with the Longest Life Expectancy (and intermediate and shortest, too)

Table 5.a
Adjusted survival probabilities, from day one, in the incident ESRD population. Y-axis percentage of ESRD population. X-axis is length of time of survival, in months.

I created the graph based on data of 5 year survival rates based on all types of dialysis combined; hemodialysis; peritoneal dialysis; and transplant. The data was taken fron  the United States Renal Data System (USRDS) Website from  http://www.usrds.org/atlas.aspx and http://www.usrds.org/2011/pdf/v2_ch05_11.pdf

Table 5.a

Adjusted survival probabilities, from day one, in the incident ESRD population. Y-axis percentage of ESRD population. X-axis is length of time of survival, in months.