Moving and grooving: should we bring the gym into the dialysis unit?

Back in 1999, UCSF researchers strapped some high tech motion detectors onto about 30 patients on dialysis and compared one week’s worth of activity to that of matched controls. Mind you, these control patients were selected to be sedentary—i.e., they told the researchers that they exercised less than once a week on average.


The patients on dialysis were 35% less active than even these sedentary controls. Similarly low levels of physical activity have been confirmed again recently; nearly 95% of patients on dialysis in this study met criteria for “low fitness.”


Okay so what? We all know that our patients tend to be over 60 years of age, and some have peripheral vascular disease or other comorbidities that limit their mobility. We already talk to them about taking their phos binders and eating less salt, do they really need advice about how much they should move about?


Here are some arguments that suggest this this just might help:


• We know that patients on dialysis tend to have a higher burden of cardiovascular disease and diabetes, compared to the general population. And exercise not only prevents a heart attack in an other wise healthy individuals, it also prevents secondary events in individuals who already have some of the comorbidities. For example patients with diabetes who walk two hours per week can drop their all cause cardiovascular mortality to one-third of that seen in sedentary diabetics.

• Just like in the diabetics, being sedentary increases the risk of mortality in our patients as well. In one of the largest observational studies to date, patients who never exercised had a 60% higher chance of dying during their first year of dialysis compared to others who reported that they at least attempted to exercise. This increase in mortality risk is the same as if the patient had an albumin of 2.5 mg/dL compared to 3.5 mg/dL for example.

• Exercise preserves function later in life. Studies have shown a reduction in falls, cognitive impairment and physical function (i.e. ability to complete activities of daily living) in elderly people who exercise.


So both from a longevity and quality of life point of view, our patients would be helped by exercise. There is a lot of back-and-forth about why patients on dialysis tendency towards being sedentary—is it the burden of comorbidity, is it a uremic toxin that saps their muscle strength, or is the procedure itself (when we talk about hemodialysis in particular)? We don’t know yet.


Other people are looking into whether to push aerobic or resistance exercise. But very few studies have tried innovative ways of incorporating exercise into the dialysis session. And in this world of expensive treatments, converting a few dialysis chairs into stationary bikes in the dialysis center may be our most cost effective intervention! Failing that, we should at least mention the bike during our rounds.


Suchi Anand, MD

Bundling Redux

Here’s an update on the recent financial upheaval in the world of dialysis reimbursement. The expanded bundling payment system was officially implemented in January 2011, and most dialysis units have now switched over to this new billing practice.

Bundling affects reimbursement to the dialysis providers (more than two-thirds of whom are affiliated with either DaVita or Fresenius in the US). Prior to January 2011, providers used to get paid about $130 per treatment for:

• Labor: nurses, techs, dieticians and social workers

• Supplies: tubing, dialyzer

• A limited number of simple laboratory tests (example: CBC and BMP)

Now Medicare has bundled those components and added:

• Medications: ESAs, Injectable (or oral) vitamin D, Injectable (or oral) iron, antibiotics if used for infection related to access/dialysis procedure, thrombolytics including TPA

• Laboratory testing: CBC, iron studies, hepatitis B, BMP, clearance calculations, PTH, ca/phos, blood cultures if drawn for infection related to access/dialysis procedure

into one lump sump payment. The total payment will go up to about $230 per treatment, with some adjustment upwards if the patient is at a low volume facility, a new start or has co-morbidities like myleodysplastic syndrome or MGUS (things that tend to make patients ESA resistant). By creating this expanded lump sum, Medicare plans to save 2% of its projected costs for 2011, mainly because it will no longer be responsible for the previously “separately billable” ESAs and vitamin D.

Rolling out in 2012 will be quality measures, which are tentatively set at:

• HgB under 10 mg/dL or over 12 mg/dL

• URR over 65% But are subject to change and debate.

If a facility doesn’t meet these quality measures, then they will get a unit wide reduction of 2% in their reimbursement. At a later date (2014), Medicare also plans to fold in oral drugs (like cinacalcet and sevelamer) into their expanded bundle.

RFN has touched on the implications of bundling before, especially the mixed feelings of physicians who are continually pressured to cut costs as they attempt to care for a vulnerable population. On the plus side, bundling eliminates the incentive to “overtreat” patients with ESAs or IV vitamin D just so the dialysis facility can bill Medicare—usually at an amount significantly above their purchase price—and generate profit.

On the other hand, patients who have a tendency to be ESA resistant, or don’t have a good working access and therefore struggle to achieve their prescribed URR, will be much less attractive to the dialysis unit. Will the trade off from reducing ESA use be more blood transfusions? Will the dialysis unit send a patient with a fever and a tunneled catheter to the ER instead of drawing blood cultures and giving antibiotics that could cut into their “bundle”? A good discussion of these issues can be found here.

The bottom line is this system has been adopted. We’ll have to wait and see if it truly affects outcomes. Luckily the DOPPS people are helping us track a number of outcomes on their well organized website.

Suchi Anand, MD