Dialyzer Reprocessing and the Bundle

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Over the last five years, many facilities that previously practiced dialyzer reprocessing, switched to single use. In speaking with those who made the change, two main reasons came to light: staff convenience and the lowered costs of entry-level dialyzers.

Dialyzer reprocessing has faced many challenges since the practice was initiated. Patient organizations and advocates have long had various and sundry reasons to reject the practice, which, in the final analysis, have been proven to be unfounded. To further complicate the subject, some dialysis professionals have had their own reservations about using one dialyzer repeatedly for the same patient with an underlying perception that the patient was being “cheated.” At the very least, some members of the dialysis staff may have felt that the process seemed to be an inconvenience that took them away from more important duties.

The safety and efficacy of dialyzer reprocessing has been proven repeatedly by the way of unbiased research, which shows that, when done properly, it represents very little risk to patients’ mortality and morbidity. In spite of this, opponents of dialyzer reprocessing have persevered in their resistance to, and denigration of the practice. Our opinion is that the practice needs to be revisited, particularly in the light of the new ESRD bundled payment, which, most likely, will be lower than what we are getting today, and for the fact that reuse continues to bring positive benefits to our patients.

Clotting studies during the hemodialysis treatment: Where did they go?

Due to risks of staff exposure to needle stick injury and OSHA, the ESRD industry, as a whole, no longer carries out clotting studies, such as Lee White or activated clotting times. As a result, ESRD providers have lost our measuring stick for heparin efficacy during hemodialysis. Since clotting times are no longer being evaluated, this means that the dialysis team is now empirically administering heparin to patients without any real clue of efficacy. Without continuous evaluation of coagulation studies, there is no way of knowing whether heparin doses are adequate enough to keep a patient’s blood therapeutically anti-coagulated. In addition, even if a patient’s hemodialysis blood circuit doesn’t clot off, without proper evaluation of the patient’s clotting times, it is possible that providers could, over a period of time, be giving the patient micro-emboli during the dialysis treatment. Imagine this happening on a continuous basis over several months, or possibly even years and the likelihood of an MI, stroke, or pulmonary embolism begins to become a real possibility.

Even if the fibers of the dialyzer appear “clear” this does not mean that the anti-coagulation of the patient and the hemodialysis blood circuit is adequate. Many “clear” dialyzers have been evaluated on the reprocessing machine only to discover that the remaining volume is well below the 80 percent cut off. The fact is that a “clear” post treatment dialyzer is no guarantee of the quality and/or efficacy of the patient’s heparinization.

If you’re not doing dialyzer reprocessing, you will never be sure whether or not your patient is adequately heparinized until your Kt/V and URR have already dropped. Even then, you’ll be scratching your head, trying to determine why your patient is not meeting the DOQI guidelines.

Getting what you pay for

Many facilities that have forsaken dialyzer reprocessing are buying “economy” dialyzers, paying between $8 and $10 per dialyzer. Remember the idiom “you get what you pay for?” Well, the meaning behind that saying is in full force when evaluating the quality of dialyzers you are purchasing for your patients.

As mentioned earlier, one of the primary reasons for the discontinuance of dialyzer reprocessing has been the advent of inexpensive, but low-performance, dialyzers. These dialyzers are considered low performance due to the fact that they have low square-meter size of the membrane. However, pore size, as well as membrane thickness, are also factors that affect overall performance of the dialyzer. These parameters vary in the quality as price of the dialyzer goes up, or, in the case of cheap dialyzers, down.

Dialysis facilities that have chosen to return to dialyzer reprocessing after going to single use have done so, economic benefit aside, simply because the lower-cost, smaller dialyzers caused Kt/Vs and URRs to drop. Why is this important? It’s important because better Kt/Vs and URRs result in higher levels of wellness for our patients. Clearly, patients who are better dialyzed have reduced need for medications, lower mortality, lower morbidity and a generalized improvement in well being. You can’t achieve such results with a cheap, middle-of-the road solutions, or fewer dialyzers.

Most facilities using economy dialyzers are having difficulty maintaining their Kt/Vs within DOQI guidelines. Once the change to non-reuse has been made, it doesn’t take long for providers to realize that the smaller, less efficient dialyzer isn’t providing the urea reduction rates they’d hoped for. As a result, in order to make up for poor dialyzer performance, they have to increase patient treatment time, which results in increased staff operational costs. So, although you’ve saved money on the dialyzer, in the end, you have lost money by extending the hours of your staff, which is the largest cost of a dialysis procedure. You’re borrowing from Peter to pay Paul and getting nowhere.

The beauty of a quality, efficient dialyzer reprocessing program is that you can buy the very best dialyzer available. This is particularly important for patients with larger than average body mass index. Not wishing to point the finger, there are many facilities using mediocre, low-square-meter dialyzers on large patients with horrible results. To make matters worse, many of these patients have no intention of running more than four hours, three times per week. Having a large two square meter plus dialyzer gives you the ability to achieve the best Kt/Vs under the most difficult circumstances (poor access with resultant poor Qbs).

Without dialyzer reprocessing, smaller dialysis facilities and chains would not be able to afford the “best” (larger) dialyzer, period.

Dialyzer reprocessing: Profit center or means of survival?

Most opponents of dialyzer reprocessing tend to focus, primarily, on the fact that the practice is only used to save money. The fact that dialyzer reprocessing is a profit center has never been disputed. However, as stated, above, this isn’t the only factor to consider when thinking about dialyzer reprocessing.

Bundling of ESRD services is coming, beginning in 2011. Additionally, we cannot forget that our nation is facing the worst financial crisis since the Great Depression. In light of these sad facts, dialyzer reprocessing is a silver lining to this dark cloud. During these tough times, ESRD providers can position themselves so they can not only survive, but succeed, in the coming bundled-rate era.

To reuse or not to reuse is no longer the question, especially for small chains and independent providers. The question now is, if you’re not reusing, how soon can you start? If you are reusing, how can you make your program more efficient and profitable?

Could larger dialysis chains benefit from dialyzer reprocessing or increased efficiencies in their program?

The answer is clearly, yes. This must take into account that the provider has strong, clearly written and enforced policies, as well as active quality assurance and continuous quality improvement programs. Thus, for the larger chains, millions of dollars could be saved and profit increased. At the same time, using the largest dialyzer available would increase quality outcomes for their patients.

Our goal, as ESRD providers, should be to provide the very best level of wellness that we can for our patients. This goal cannot be accomplished using economy dialyzers. If your facility is using a cheap dialyzer, your large patients should be closely scrutinized when monthly labs are reviewed.

It goes without saying that patients who are well dialyzed have fewer complications, better phosphorus control, blood pressure control, lower rates of hospital admissions, a higher overall level of wellness and a lower mortality rate.

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