On its surface, dialysis might look like a model of health equity in the United States — facility-based treatments are broadly available in local communities and a universal payment benefit reduces financial barriers to care. The Centers for Medicare and Medicaid Services has also recognized the need to ensure equal care for socially and economically disadvantaged patients by proposing changes to the current model that directly address health equity.

While these areas of progress are encouraging, the way in which chronic kidney disease (CKD) is treated is far from adequate for many. Incomplete pre-dialysis patient education and fragmented communication across multidisciplinary care providers presents enduring barriers to optimal patient care. Without addressing these underlying issues, we run the risk of increasing access to a system that ultimately does not work for our most vulnerable patients and the families it’s meant to support.

According to the United States Renal Data System (USRDS) 2020 Annual Data Report, adjusted mortality rates for prevalent dialysis patients in the U.S. declined 17.3 percent from 2008 to 2018. This suggests advances in quality of care and technology may be having a demonstrable effect on health outcomes. But if we look closer, because of its tendency to negatively impact patients’ quality of life, dialysis remains low in cost utility analyses, expressed as health and quality of life gains per unit of expenditure.

The World Health Organization’s (WHO) framework for determining the economic value of a health care treatment, supported by many health economists and ethicists, involves counting years of life saved, weighted by the quality of those years, to determine which health care services are providing the most value for their cost. In the case of the CKD continuum, over time, receiving care can be so time-consuming, expensive, and difficult that many patients – especially those living in rural communities and/or in poverty – do not receive proper care at all.

To drive real change across the CKD industry, two key strategies should be considered, each with the potential to improve patient outcomes while lowering healthcare costs.

Strategy 1: Increase in pre-dialysis CKD Care

A 2016 study found that up to 63% of dialysis patients start as “crash-landers” — presenting, without warning, with kidney failure that urgently requires kidney replacement therapy. These unplanned dialysis starts are associated with increased patient morbidity and mortality, as well as lower quality-of-life scores, and come at a much higher cost, often due to emergency room (ER) visits, hospitalizations, and sometimes even critical care admissions. 

When universal screening and surveillance programs for those at risk for CKD are applied during the early stages of a patient’s journey, overall quality of care and treatment can be improved at lower costs. For example, a 2017 study found that screening for CKD in Canadian indigenous peoples — a group with rates of kidney failure that are two to four-fold higher than the non-indigenous general Canadian population — is especially cost-effective. However, CKD screening and diagnostic practices also need to be reassessed to best serve all patients — in the U.S., historical practices surrounding race based estimated glomerular filtration rate (eGFR) testing, which is used to diagnose CKD, have been hypothesized to have led to potential misdiagnoses and stigma within the Black population. A movement to remove race from eGFR calculations is a step in the right direction to alleviating this bias.

For patients that already have late-stage CKD, enhanced telemonitoring and virtual ward technologies may reduce the rate of suboptimal dialysis starts. However, the costs of any such intervention must be weighed against the potential benefits. Research has shown that telemedicine can save money and time, especially for patients who live in rural communities. However, telemedicine-based cost and time savings for patients requiring in-center dialysis treatment three-times a week in an urban setting are still unclear.

Strategy 2: Invest in flexible care models

As an industry, we need an increased commitment to treat patients where they live — in the case of kidney care, this means bringing dialysis directly to patients in any setting and removing financial barriers to set patients up in their own homes. Home dialysis is not only preferred by many patients but can alleviate costs, discomfort and patient indignity. Home dialysis allows for more flexible treatment times, accommodating work or childcare needs, and is a form of empowerment when so many other liberties have been taken from patients who are suffering from kidney failure.

Approximately 10% of all kidney failure patients are residents of skilled nursing or long-term acute care facilities, where the prevailing practice is to transport patients from a nursing home to a dialysis clinic multiple times per week. This puts the highest risk patients in close contact with others during transportation and treatment, causing unnecessary vulnerability and increasing their chances for further health complications.

CKD care coordination technology companies are rising to the occasion to help close gaps in access, improve patient experiences, and ultimately drive better outcomes. However, studies indicate that ESRD patients of color are more likely to receive in-center hemodialysis versus home dialysis, despite this population arguably having the most to gain from properly implemented and managed home care. For example, Mehorta et al. found that, among individuals undergoing home dialysis, Black patients had a significantly lower death risk than white patients.

A renewed mindset to achieve health equity

We cannot accept that our industry is succeeding in the fight for health equity at face value. Instead, we must examine the deeper structural challenges that exist to make certain that all people living with CKD, irrespective of race and wealth, can access the quality, convenient treatment options that they deserve. Through increased pre-dialysis support and flexible care models, the industry at-large can improve patient outcomes with cost-effectiveness that provides a more equitable experience. 

Paul Komenda, M.D., is chief medical officer, Quanta Dialysis Technologies. Shaminder Gupta, M.D., is chief medical officer, Monogram Health.