An article in today’s New York Times by Gina Kolata says it has, and to me it seems like it’s about time. Kolata’s report notes that a committee of nephrologists assembled by the Renal Physicians Association recently drew up guidelines on which patients are appropriate dialysis candidates from a medical perspective and which are not, a test that until now has often not been applied to patients with end-stage renal disease. The new guidelines call for physicians and patients to discuss the patient’s condition and arrive at a mutually agreed on decision as to whether dialysis is the right course of action.
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One of their criteria: Physicians treating a patient should ask themselves whether, even with dialysis, the patient likely has a year to live.
As the Times article summarizes, in 1972 Congress made free dialysis a right for just about any American with failing kidneys. The program now includes 400,000 patients with an annual bill of $40-$50 billion, and with those older than 75 the fastest growing segment of the dialysis patient load. The 1972 law never anticipated a program of this scope, and at a time when Congress is haggling over whether the entire U.S. budget should get cut by $30 billion or $60 billion, a $45 billion program that has ballooned into a clinically questionable, medically-blind monster stands out. Aren’t there more pressing and cost-beneficial ways to spend America’s health care dollars than providing dialysis to all comers?
I have heard many cost-benefit analyses in my years as a medical journalist, and I never fail to be struck that the perennial benchmark is the quality-adjusted life years–the QALYs–that dialysis delivers. Since American society accepts the dialysis entitlement, any other treatment that delivers as much medical bang as dialysis for a buck is judged acceptable. Now, finally, American nephrologists have questioned the premise that underlies this benchmark.
—Mitchel Zoler (on Twitter @mitchelzoler)