Predictors of the excessive mortality rates of dialysis patients in the United States.
It is now well recognized that the United States has the highest mortality rate for end-stage renal disease patients receiving dialysis among the industrialized nations. The possible causes of this almost 25% gross mortality rate (23.6% in 1992) are becoming clearer. After numerous investigations of the various possibilities, it is now evident that the causes are multifactorial. Basically, the US reimbursement for dialysis payment rate has been kept low (essentially no increase since 1973) by allowing inflation to advance and maintaining the actual costs. The industry has responded in a number of ways, some of which have proven harmful. For example, the reuse of dialyzers was probably reasonable and has not proven to be a problem: reductions in staff for older and sicker populations has probably been harmful to the patient's well being; and the shortening of dialysis treatments may have produced more problems than any other change. Essentially, as patients receive less dialysis they feel worse and lose their appetite, thus resulting in weight loss. Frequently dialysis is reduced further because of reduction in certain chemical markers, eg, blood urea nitrogen, that nephrologists use as clinical measurements. This results in a malnourished patient with a low serum albumin level. It is believed but not yet proven that an increase in the dialysis prescription, ie, more dialysis, can reverse this decline. Currently the United States faces the challenges of reducing its mortality rate for end-stage renal disease patients to compare with that of other industrial countries while remaining at the current reimbursement rate, which is less than half that of Germany and one quarter that of Japan.
Hull
A R
AR
University of Texas Southwestern Medical School, Dallas.
D006801:Humans; D007676:Kidney Failure, Chronic / Q000401:mortality* / Q000628:therapy; D006435:Renal Dialysis / Q000401:mortality*; D012307:Risk Factors; D014481:United States / Q000453:epidemiology