Comparing Outcomes for Dialysis Patients Around the World: The Debate Continues

DaVita is entering the world of international dialysis in a big way. We are partnering with doctors in Singapore, India, China, Malaysia, Saudi Arabia, Germany and other countries. As we embark on this exciting adventure, we again are faced with the nagging perception that dialysis outcomes in the United States are worse than those in other parts of the world. Two recent articles provide fascinating perspectives on this important issue.

Cheng et al. from Beijing, China, examined mortality rates in prevalent hemodialysis patients in Beijing and compared these with data from USRDS. (1) The average mortality rate in Chinese patients had been reported at about 10% during the study years (2007–2010), nearly half that reported for U.S. patients during the same time period. The authors then examined many of the purported factors that might confound and/or explain this comparison. There were clear demographic differences in the populations; in the Chinese group there was a preponderance of males, only 32% of patients were over 65 years old and only 18% had diabetes as a cause of ESRD. Of interest was the fact that 49% of deaths were due to vascular disease, including CVD and stroke. After adjustment for the differences in demographics, including race, Beijing patients had a relative risk of death compared to white U.S. patients of 0.16, 0.26 and 0.42 for 2007, 2008 and 2009, respectively, and similar survival advantage compared to Asian U.S. patients. Of note is the fact that the Beijing patients’ mortality increased 61% from 2007 to 2010, while U.S. patients had a decrease in mortality of nearly 14% between 2004 and 2009 (dates for which data is presented), suggesting that the decreasing gap in mortality rates is primarily related to a worsening rate in Beijing, not to improvements in survival rates in the United States. Despite the closing of the gap, survival in Beijing still exceeds that in the United States. The authors conclude that practice patterns rather than patient differences explain the findings; and in particular the time nephrologists spend with their patients is impactful. In Beijing physicians are present during all treatments. Another factor that may also be important is the significantly lower rate of catheter use in Beijing

The idea that practice patterns rather than management of anemia, adequacy or other aspects of care drive differences in outcomes is not a new one, but two recent studies examine this question in much greater detail (2,3). Slinin and colleagues evaluated the impact of provider-patient visit frequency on hospitalizations and mortality in dialysis patients. Greater frequency of provider visits was associated with a significant reduction of hospitalizations, although there was no association with mortality.

Kramer and colleagues from Amsterdam examined macroeconomic indicators in various countries in an attempt to explain mortality differences. The indicators included GDP per capita; healthcare expenditures as a percentage of GDP; private for-profit share of hemodialysis (HD) facilities; HD-facility reimbursement as proportion of GDP; prevalent dialysis patients per nephrologist; % of diabetes as a cause of renal disease; age- and sex-related mortality risk of the incident dialysis population; and confounders including human development index, responsiveness index, public share of healthcare expenditure and general population-health indicators (including cardiovascular mortality and life expectancy at age 60). Finally, HD-facility reimbursement method, prevalent dialysis patients per center, and incident-patient age and gender were included in the analysis. The key findings were that a higher GDP per capita and a higher healthcare expenditure as a percentage of GDP were associated with a higher two-year mortality rate on dialysis. Perhaps “richer” countries have a more liberal acceptance policy for putting patients on dialysis, as the authors suggest. In addition, a higher intrinsic mortality risk of the dialysis population—based on the mortality of the general population and age and sex standardization of the incident patient population in a country—as shown by others (4,5)—is key to the differential survival rates.

So what are the lessons for U.S. nephrologists and for DaVita as it embarks on its international journey? It seems clear that in the United States, there is no substitute for nephrologists spending time with dialysis patients. The dramatic trend—driven by current reimbursement and increasing time demands—toward monthly nephrologist visits, with additional visits made by other caregivers, arguably is contributing to the problem. While mortality has slowly, steadily improved, none of us can be happy with the current high mortality rate. Recommitting to engaging with our patients is one step that may help. Internationally for DaVita, we must approach our partners with openness and a willingness to learn from them. What are their clinical goals and metrics? How do they interact with their patients and focus on the key areas that drive better outcomes? What do they think are the reasons they have such excellent outcomes? And for those parts of the world where outcomes are not so good or even being measured, two of the great gifts we can bring to nephrologists and patients are rigor and a process for defining the important outcomes, measuring performance and focusing on what is important to patients everywhere—to lead as long and as satisfying a life as possible.

We should all remember as we ponder how we care for our patients in the United States or work with our partners in other parts of the world that often it is they and not we who have many of the answers. As Confucius said,

“He who speaks without modesty will find it difficult to make his words good.”

At the end of the day, nephrologists everywhere need to share their knowledge and experiences, and consider the words of Buddha, as well:

“You should respect each other and refrain from disputes; you should not, like water and oil, repel each other, but should, like milk and water, mingle together.”

Striving to bring quality to life,
Allen R. Nissenson, MD

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1. Cheng X et al. Mortality Rates among Prevalent Hemodialysis Patients in Beijing: A Comparison with USRDS Data. Nephrol Dial Transplant 0:1–7, 2012.
2. Kramer A et al. Exploring the Association between Macroeconomic Indicators and Dialysis Mortality. Clin J Am Soc Nephrol 7:1–9, 2012.
3. Slinin Y et al. Association of Provider-Patient Visit Frequency and Patient Outcomes on Hemodialysis. J Am Soc Nephrol 23:1560–1567, 2012.
4. Van Dijk PC et al. Effect of General Population Mortality on the North-South Mortality Gradient in Patients on Replacement Therapy in Europe. Kidney Int 71:53–59, 2007.
5. Yoshino M et al. International Differences in Dialysis Mortality Reflect Background General Population Atherosclerotic Cardiovascular Mortality. J Am Soc Nephrol 17:3510–3519, 2006.