At the same time, Medicare paid for dialysis quite generously in the beginning and so there was a rapid proliferation of dialysis units, both nonprofit and for-profit, across the country, "which again wasn't necessarily a bad thing," Blagg said. National Medical Care from Boston, the first for-profit dialysis group expanded rapidly and eventually was purchased by Fresenius that now treats about a third of the patients in the United States.
Unfortunately, as the years went on the use of HHD began to fall and fewer and fewer patients were receiving this treatment at home. At the same time the use of another home treatment, peritoneal dialysis, increased from the late 1970s.
"For HHD I think this was lowest about 2002 when there were between 1,500 and 1,600 HHD patients in the U.S.; there's now between 6,000 and 7,000 patients on this, the best form of dialysis," Blagg said. "Peritoneal dialysis was about 14 percent 20 years ago and then regressed down to about 7 percent but is beginning to increase again."
In 1995, a Toronto group reintroduced overnight HHD and used it five or more nights a week and showed that this gave the best survival results of any dialysis modality. Since then two home-specific machines have come on the market the second of which has been a major factor in the increase in HHD in the United States. More new machines are coming
Training a patient for HHD is expensive and Medicare has never covered these costs adequately, but after a patient is trained and dialyzing at home the costs decrease considerably because the patient isn't depending on a nurse or physician while being dialyzed in a unit. They do everything themselves or with the assistance from a family member or friend.
Over the last 40 years there have been many successes. The first was the obvious, paying for dialysis and transplantation. From new drugs to clinical studies showing that more frequent dialysis truly is better, progress has been made. There are many more changes that need to occur and the next 40 years will have to be a test if improvements can be made. Some major changes required are an increase in reimbursement for HHD training and an extension in coverage for immunosuppressive drugs.