When to dialyze?
Treating people with chronic kidney disease is logistically challenging — just ask Ladan Golestaneh, a nephrologist in the Bronx. She has to see some of her patients every few weeks to adjust medications and keep their kidneys functioning.
But sometimes, patients don’t show up to their appointments. Other times, Golestaneh doesn’t have any open slots. People’s disease gets worse, and they might have to get put on dialysis — an outcome that could have been delayed or prevented if they got the medical care they needed.
“This is actually a very frustrating problem,” she says.
Dialysis is an expensive and inconvenient treatment given to more than half a million Americans. But sometimes, it’s easier for doctors to put their patient on dialysis — where they’ll be getting more consistent care — rather than continuing to try to treat them in the office.
That’s one of the implications of a paper that Golestaneh, also a professor of medicine at Montefiore Medical Center in New York City, and her colleagues published last week in JAMA Network Open. Doctors may be sending patients to dialysis early because they don’t have the time or resources to keep taking care of the patients themselves, Golestaneh says.
The paper found that people living in areas with more dialysis clinics tend to start dialysis earlier than people living in places with fewer clinics.
“What it represents is the lack of ability of health systems to really keep a close eye on the sickest patients,” Golestaneh says.
Dialysis can be taxing and time-consuming, requiring several hours-long weekly appointments at a dialysis center. “It’s like a part-time job,” Golestaneh says. And it’s expensive — Medicare, which pays for most of dialysis, shells out an average of $90,000 a year per patient.
To make time and resources more available to patients, Golestaneh says that government insurance programs like Medicare should financially incentivize health systems to keep patients healthier and not put them on dialysis. The government is working on this through experimental programs that Golestaneh’s medical center is a part of.
The health-care system could save money — and people with kidney disease might live longer without the disruptions of dialysis — if patients had more access to that health care, she says.
“If I could wave my magic wand,” says Golestaneh, she would ask for more pre-dialysis care in order to help “delay the need for dialysis as much as possible.” — Ike Swetlitz
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