The mortality rate among renal dialysis patients varies tremendously from one dialysis center to another.
Even adjusted for how sick the patients are, mortality is as low as 10 percent in some places, and as high as 30 percent elsewhere. And, a new study helps explains why.
“More activated and engaged patients,” better “physician communication,” and “stronger interpersonal relationships” account for much of the difference, say the study report authors. Other factors are more competent dietitians and superior overall coordination and staff management. Together, these factors explain about one-third of the difference in mortality rates between centers with high death rates and centers with low death rates.
The number of deaths prevented by the better-communicating dialysis centers is probably larger than you might expect. It appears to run in the tens of thousands every year. (The overall average mortality rate is about 20 percent.) In 2008, Medicare alone paid for renal dialysis of more than 450,000 patients.
There’s also an economic side to this tragedy. Also in 2008, the total Medicare tab for end-stage renal disease was $27 billion. This amounts to six percent of all Medicare expenditures.
It’s too bad Medicare can’t insist on better communication practices in order to prevent unnecessary deaths associated with this huge outlay. Medicare is trying to pay centers a flat fee, or “bundled payment,” but generally is prohibited by Congress from tying payments to high-quality care.
The study appears in the September 28 issue of the Clinical Journal of the American Society of Nephrology. The authors are Brennan Spiegel of the VA system in Los Angeles, and colleagues. The article is summarized by Cheryl Clark in the October 21 HealthLeaders Media.
Patients at centers with low mortality tend to stay for their entire session, learn from staff, and comply with dietitians’ advice, according to the study. “In short,” says Clark, “it sounds like these lower mortality centers offer a friendlier environment for the long hours patients must be there every week.”
But, it’s worth emphasizing that it’s the patients themselves who make the difference.
“Personnel in facilities with low mortality rates perceive their patients to be more cooperative, willing to learn, compliant, self-efficacious, independent, and accountable,” the study authors say.
Many experts in the medical and health policy fields tend to downplay the importance of physician-patient communication. This study shows they’re wrong to discount communication: it can make the difference between life and death.
A final note: it’s probably no accident that Spiegel, the lead author, works out of the VA system. The VA has led the way on many advances in health care, from end-of-life care to team-building.