Dr. Blagg came from England in the early 1960s to practice at the University of Washington, and ran Northwest Kidney Centers in Seattle from 1971 until 1998. A longtime supporter of home hemodialysis [home HD], Dr. Blagg trained the second patient in Seattle to use such a system, in 1964.

“As far back as 1973, the government had intentions of encouraging kidney transplantation and home dialysis, and in the 1980s even made the payments for home dialysis and in-center dialysis equivalent –the composite rate,” he recalls.

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As of December 31, 2008, 354,600 patients were receiving HD and 26,517 were on peritoneal dialysis, according to the U.S. Renal Data System. The home HD population was 3,826 individuals.

The for-profit dialysis providers have had a strong influence on such matters, Dr. Blagg says. “If you’re going to run a dialysis unit, the easiest thing to do is in-center dialysis,” he comments. “And in the early days of the program Medicare paid so well for center dialysis, and private insurers paid incredible amounts, so if you were a for-profit provider and were interested in money and wanted to please your stockholders, why would you set up a home-dialysis program with all the issues and difficulties? Now with the new bundling and so on, there may be a bit more pressure on the idea of using home dialysis or PD [peritoneal dialysis] because it’s less expensive.”

The tide may already be turning: Dr. Blagg is pleased to note that over the past few years, for-profit dialysis units appear to becoming more interested in setting up not only home HD and PD, but also nocturnal dialysis—a practice popular in Australia and New Zealand and championed by Dr. Blagg, who believes that longer and/or more frequent dialysis is easier on and safer for the patient than is undergoing the treatment for a few hours a day, a few days a week, and feeling wiped out after every session.

 “I think it’s a process that’s going to take quite a time to change,” Dr. Blagg says. He said he believes the interest in more frequent dialysis, the development of home-use machines that are more specifically patient-friendly, and an increase in talks about home HD and PD in the last few years bodes well for the future of these alternative dialysis delivery systems.

An outside critique of U.S. dialysis

John Agar, OAM, MBBS, is a self-described enthusiast for home dialysis. In fact, he states exactly that on www.NocturnalDialysis.org, the Web site he helps maintain for Geelong Hospital in Victoria, Australia, where he is also Director of Renal Services. As Dr. Agar makes clear on the Web site, he is no fan of the way dialysis services are delivered in the United States:

In Geelong, we sustain >40% of our total dialysis patient pool at home … currently 22% of all our patients are on home haemodialysis and 18% on home peritoneal dialysis (both manual  [continuous ambulatory] PD and automated PD). Of our haemodialysis patient group alone, 28% are currently at home. This compares with ~14% in Australia and New Zealand as a whole and with less than 1% in the US! I think we have a good balance in our program and that the US, in theirs, does not—though this is a personal view.

“The poor performance of the U.S. in dialysis—and this is not just home dialysis but all dialysis—is steeped in the history of how dialysis was originally funded in the U.S.,” Dr. Agar tells Renal & Urology News.