What Tassin can teach us

The quality of dialysis care in the United State is judged, in part, by a collection of quality measures imposed and updated yearly by CMS. Guy Laurent, MD, creator of the kidney clinic Tassin-la-Demi-Lune in France in 1969, who recently died at 83 years old, would have laughed at the idea of government-regulated dialysis care because dialysis at his clinic was like no other. Along with Bernard Charra, MD, they offered patients an overnight dialysis experience complete with four-course meals and wine. Many clinicians came to Tassin to study their approach and results.

“Long, slow hemodialysis (3 × 8 hours/week) has been used without significant modification in Tassin, France, for 30 years with excellent morbidity and mortality rates,” Charra wrote in 1999.¹“A long dialysis session easily provides high Kt/V_urea and allows for good control of nutrition and correction of anemia with a limited need for erythropoietin (EPO). Control of serum phosphate and potassium is usually achieved with low-dose medication. The good survival achieved by long hemodialysis sessions is essentially due to lower cardiovascular morbidity and mortality than in short dialysis sessions. This, in turn, is mainly explained by good blood pressure control without the need for antihypertensive medication.”

“[Increasing] the length of the dialysis session seems to be the best way of achieving satisfactory long-term clinical results,” they wrote.

Contemporary followers

Istenio Pascoal, MD, and his team of nephrologists from Centro Brasiliense de Nefrologia & Dialise in Brasilio, are following in Laurent’s footsteps. The group recently presented 10-year results of their study on the benefits of 7-day-a-week dialysis.² In the study, they noted that “in-center hemodialysis programs usually operate Monday through Saturday, in two conventional thrice-weekly schedules: Mon-Wed-Fri or Tue-Thu-Sat. On Sundays, during the long 72-hour interval, dialysis centers are regularly closed, and patient care relies on emergency rooms, leading to concerns of higher mortality over weekends.”

Istenio Pascoal and his son Pedro presented results of the study on 7-days-a-week dialysis service during last year’s Kidney Week. Source: Centro Brasiliense de Nefrologia & Dialise in Brasilio

After setting up a 6-days-a-week, in-center short daily hemodialysis program, the center started to provide dialysis treatments on Sundays. The researchers studied 166 unselected patients who received in-center short daily hemodialysis treatments six to seven times per week, lasting 2 hours with ultrapure dialysate and single-use high flux dialyzer.

Prior studies from multiple fields have demonstrated that hospital admission on the weekend is associated with poorer patient outcomes, they reported.

“Seven-day dialysis services may well narrow the gap between weekday and weekend dialysis mortality, as supported by our consistently low hospitalization and mortality rates,” Pascoal said.

From June 2007 to May 2017, 24 of 160 cumulative short-daily hemodialysis patients extended their schedule from six to seven treatments per week, nine patients chose Saturdays as their regular day-off and the remaining 127 patients had occasional dialysis on Sundays to replace most of the missed treatment that occurred during their original track.

However, here is a key statement. “Over the 10-year study period, the average missed treatment rate was 1.47% or 4.5 days per patient-year and the hospitalization rate was 0.4 admissions per patient-year. In parallel, the 5-year cumulative patient survival rates were 98%, 92%, 82%, 69% and 60% at 12, 24, 36, 48 and 60 months, respectively,” Pascoal and colleagues wrote.

One of the key ingredients to success in patients coming in 7 days a week was finding a motivational tool. The dialysis center agreed to have them picked up at their homes or place of business.

Think outside the box

What about the cost of such a program?

“From an economic point of view, extra dialysis treatments delivered to our patients who extended their schedule from six to seven times a week (2.25%) exceed the residual missed treatment rate (1.47%), and has allowed our Sunday dialysis to become, from concept to practice, a self-sustaining program,” Istenio Pascoal, CEO of Centro Brasiliense de Nefrologia & Dialise in Brasilio, said.

“We are excited to be sharing this data with the entire renal care community. Altogether, this Sunday dialysis program has been a convenient, protective and economically viable initiative.”

Thinking outside of the box can make a difference on the bottom line and on patient satisfaction surveys. Follow Guy Laurent, Bernard Charra and Istenio Pascal’s lead. There is always a better way.

References:

Charra B, et al. Nefrologia i Dializoterapia Polska. 2006;10;141-146.

Pascoal P, et al. Abstract SA-PO682. Presented at: Kidney Week; Oct. 31-Nov. 5, 2017; New Orleans.

For more information: Mark E. Neumann is Editor-in-Chief of Nephrology News & Issues.