Bring­ing the Revo­lu­tion in Kid­ney Care to Canada’s Re­mote Com­mu­ni­ties

Policy - - In This Issue - Stephen Thomp­son

In less than a cen­tury, end-stage kid­ney dis­ease has gone from be­ing a death sen­tence to be­ing a chronic but man­age­able con­di­tion. More re­cently, in­no­va­tions in med­i­cal tech­nol­ogy have made it pos­si­ble for dial­y­sis pa­tients to lead less re­stricted, more ac­tive lives. And it means lower costs and greater ac­cess for Cana­di­ans, es­pe­cially those who live out­side ma­jor pop­u­la­tion cen­tres.

Ev­ery great in­ven­tion has an ori­gin story. While most peo­ple think of the dial­y­sis ma­chine as an in­her­ent el­e­ment of our med­i­cal land­scape, the story of its cre­ation be­longs in the an­nals of man­i­fest ge­nius with Alexan­der Gra­ham Bell’s tele­phone, Marie Curie’s dis­cov­ery of ra­dioac­tiv­ity and Alan Tur­ing’s pi­o­neer­ing Univer­sal Ma­chine.

In 1940, af­ter the Nazi in­va­sion of Hol­land, Dr. Willem J. Kolff moved

from Gronin­gen to a ru­ral hos­pi­tal in Kam­pen rather than co­op­er­ate with the oc­cu­py­ing force. While there, Dr. Kolff, moved by the ex­cru­ci­at­ing fate of pa­tients stricken by kid­ney fail­ure, be­gan refining his idea for a ma­chine that could ful­fill the kid­ney’s detox­i­fi­ca­tion du­ties out­side the body. The early pro­to­types in­cluded the use of sausage cas­ings, or­ange juice cans and a wash­ing ma­chine. Af­ter more than a dozen failed at­tempts, Dr. Kolff’s ar­ti­fi­cial kid­ney saved the life of its first pa­tient in 1945 and the age of dial­y­sis was born. (Mean­while, Dr. Kolff had also saved the lives of more than 800 peo­ple, many of them Dutch Jews, by hid­ing them in his hos­pi­tal.) In 1950, he em­i­grated to Amer­ica and went on to build the first ar­ti­fi­cial heart. Today, mil­lions of lives world­wide are be­ing ex­tended by the process Willem Kolff first en­vi­sioned amid the duress of war on the cer­tainty that hu­man­ity’s in­stinct for sav­ing rather than de­stroy­ing life would pre­vail.

In its 2017 re­port, High Risk and High Cost: Fo­cus on Op­por­tu­ni­ties to Re­duce Hos­pi­tal­iza­tions of Dial­y­sis Pa­tients in Canada, the Cana­dian In­sti­tute for Health In­for­ma­tion said that 36, 251 Cana­di­ans out­side Que­bec were liv­ing with end-stage kid­ney dis­ease (ESKD)—an in­crease of 36 per cent since 2006. That in­crease, largely due to the epi­demi­o­log­i­cal im­pact of ag­ing baby boomers, makes life­sav­ing, cost-sav­ing in­no­va­tion all the more ur­gent.

There have been so many im­prove­ments on the stan­dard dial­y­sis ma­chine of the sec­ond half of the 20th cen­tury that what was once a life-al­ter­ing prog­no­sis is now far less so. For decades, if you knew any­one—or of any­one—on dial­y­sis, the one thing you knew was that they were teth­ered to a ma­chine in a hos­pi­tal mul­ti­ple times a week. While it was the op­po­site of a death sen­tence, dial­y­sis meant a cir­cum­scribed life with­out travel and, ab­sent an ac­com­mo­dat­ing em­ployer, with lim­ited pro­fes­sional pos­si­bil­i­ties.

For many pa­tients, thanks to break­throughs in med­i­cal tech­nol­ogy, the pic­ture of life on dial­y­sis in 2018 is vastly dif­fer­ent. In he­modial­y­sis (HD) the pa­tient’s blood is still cir­cu­lated to an ex­ter­nal dial­y­sis ma­chine, which fil­ters wastes and ex­tra wa­ter from the blood be­fore re­turn­ing it to the body. Con­ven­tional HD is typ­i­cally per­formed three days a week for three to four hours per ses­sion, ei­ther at home or in a hos­pi­tal. But many pa­tients liv­ing with ESKD can now also use peri­toneal dial­y­sis (PD), which can be man­aged by pa­tients out­side a clin­i­cal set­ting. First in­tro­duced in 1983, it al­lows for greater mobility and in­de­pen­dence and less dis­rup­tion of the pre­dial­y­sis sta­tus quo for most pa­tients. There are two main types of PD: con­tin­u­ous am­bu­la­tory PD (CAPD) and au­to­mated PD (APD). Both in­volve the fil­ter­ing and evac­u­a­tion of tox­ins and waste prod­ucts with the flush­ing of a cleans­ing fluid called dialysate in­serted through a catheter di­rectly into the ab­domen. Treat­ments can be self­ad­min­is­tered at home, at work or even while trav­el­ing.

In its March, 2017 re­port Dial­y­sis Modal­i­ties for the Treat­ment of End-Stage Kid­ney Dis­ease, the Cana­dian Agency for Drugs and Tech­nolo­gies in Health (CADTH) said the avail­able ev­i­dence weighed in their health tech­nol­ogy as­sess­ment showed no dis­cernible dif­fer­ence in ef­fec­tive­ness be­tween clin­i­cal-set­ting and home dial­y­sis, and that a “home first” ap­proach for dial­y­sis modal­i­ties should be con­sid­ered. “The ev­i­dence tells us that in­cen­tre and home-based dial­y­sis of­fer sim­i­lar ben­e­fits in terms of clin­i­cal out­comes,” said Dr. Brian O’Rourke, Pres­i­dent and CEO of CADTH. “And in terms of of­fer­ing pa­tients and care­givers more choice around treat­ment op­tions, and re­al­iz­ing some cost sav­ings in the health sys­tem, this work tells us that we should be con­sid­er­ing how home-based dial­y­sis could be more ef­fec­tively im­ple­mented.” In June, 2016, in keep­ing with our record of—and com­mit­ment to—med­i­cal tech­nol­ogy in­no­va­tion, Bax­ter re­ceived ap­proval from Health Canada for the Amia au­to­mated peri­toneal dial­y­sis cy­cler. With our cloud­based Share­source re­mote pa­tient man­age­ment tech­nol­ogy, Amia pro­vides the first treat­ment mech­a­nism with two-way con­nec­tiv­ity be­tween the de­vice in the pa­tient’s home and the clinic, al­low­ing doc­tors and nurses to mon­i­tor the treat­ment re­motely and ad­just pre­scrip­tions in real time. At Bax­ter, we sup­port these

In its 2017 re­port, High Risk and High Cost: Fo­cus on Op­por­tu­ni­ties to Re­duce Hos­pi­tal­iza­tions of Dial­y­sis Pa­tients in Canada, the Cana­dian In­sti­tute for Health In­for­ma­tion said that 36, 251 Cana­di­ans out­side Que­bec were liv­ing with end-stage kid­ney dis­ease (ESKD)—an in­crease of 36 per cent since 2006. That in­crease, largely due to the epi­demi­o­log­i­cal im­pact of ag­ing baby boomers, makes life-sav­ing, cost­sav­ing in­no­va­tion all the more ur­gent.

At Bax­ter, we sup­port these re­nal pa­tients in their homes, and the con­nec­tion our em­ploy­ees have with these pa­tients is of­ten very per­sonal. We live and see pa­tient sto­ries ev­ery day, and our care and pas­sion drives us to do more.

re­nal pa­tients in their homes, and the con­nec­tion our em­ploy­ees have with these pa­tients is of­ten very per­sonal. We live and see pa­tient sto­ries ev­ery day, and our care and pas­sion drives us to do more.

Tele­health has been a crit­i­cal part of our drive to in­crease ac­cess, im­prove ef­fi­ciency of care and drive bet­ter out­comes- es­pe­cially in Canada, a coun­try sec­ond-largest in the world by area but with only 35 mil­lion in­hab­i­tants. The com­bined treat­ment im­pacts of the digital revo­lu­tion on health care ac­cess via tele­health and on prod­ucts and ser­vices through med­i­cal tech­nol­ogy in­no­va­tion has, in turn, rev­o­lu­tion­ized our ap­proach to pa­tient care, es­pe­cially among pre­vi­ously un­der-served pop­u­la­tions. In Canada, Indige­nous com­mu­ni­ties in re­mote ar­eas top that list. Indige­nous peo­ple in Canada have an ex­cep­tion­ally high bur­den of kid­ney dis­ease, with a rate of ESKD four times higher than that among non­Indige­nous peo­ple. While di­a­betes is the lead­ing cause of ESKD in Indige­nous pa­tients, per the Jan­uary 2018 re­search ar­ti­cle Bar­ri­ers to Peri­toneal Dial­y­sis in Abo­rig­i­nal Pa­tients, a com­bi­na­tion of med­i­cal and so­ci­etal fac­tors all con­trib­ute to this grow­ing bur­den of ESKD. The study, con­ducted by re­searchers from McMaster Univer­sity, Hof­s­tra Univer­sity, the Univer­sity of Ot­tawa and Queen’s Univer­sity with fund­ing from Bax­ter, con­cluded that PD could pro­vide an al­ter­na­tive to in-cen­ter he­modial­y­sis for those liv­ing in ru­ral ar­eas. With ap­prox­i­mately half of Canada’s Indige­nous pop­u­la­tion liv­ing out­side ur­ban cen­ters, in-cen­tre HD usu­ally re­quires re­lo­ca­tion to an area with a hos­pi­tal dial­y­sis fa­cil­ity. Pa­tients who have re­lo­cated to ac­cess HD suf­fer a loss of com­mu­nity, cul­tural and spir­i­tual iso­la­tion, and alien­ation from fam­ily and friends, ef­fec­tively mak­ing them “health care refugees.”

The phe­nom­e­nal changes of the past two decades, es­pe­cially in health care, have re­cal­i­brated the mind­sets of many com­pa­nies, in­clud­ing Bax­ter, as we ad­dress both the op­por­tu­ni­ties and chal­lenges of in­creased con­nec­tiv­ity—in­clud­ing data pro­tec­tion and pa­tient pri­vacy.

In 2014-15, Non-In­sured Health Ben­e­fits Med­i­cal Trans­porta­tion ex­pen­di­tures by the fed­eral gov­ern­ment amounted to $356.6 mil­lion or 34.7 per cent of to­tal NIHB ex­pen­di­tures. For Indige­nous pa­tients who re­quire med­i­cal treat­ment, in­clud­ing dial­y­sis, in ur­ban cen­tres away from their homes, lo­gis­tics take over their lives. A Fe­bru­ary 2017 re­port by the Cana­dian In­sti­tute for Health In­for­ma­tion said that Indige­nous ESKD pa­tients are 30 per cent more likely to be ad­mit­ted to hos­pi­tal due to a dial­y­sis in­fec­tion, partly be­cause they must travel longer dis­tances to re­ceive treat­ment, mean­ing prob­lems don’t get caught early. We now have the tech­nol­ogy to ad­dress these is­sues. In 2005, Bax­ter Re­nal Ther­apy Ser­vices Colom­bia launched a pilot pro­gram to es­tab­lish re­mote PD cen­ters in Colom­bia to help over­come ge­o­graphic and fi­nan­cial ac­cess bar­ri­ers for pa­tients de­sir­ing PD ther­apy. While the ter­rain and cli­mate con­di­tions in the moun­tain­ous South Amer­i­can coun­try are dif­fer­ent from those in Canada’s re­mote Indige­nous com­mu­ni­ties, they present sim­i­lar bar­ri­ers to dial­y­sis treat­ment. The study demon­strated that, with the sup­port of a re­mote PD cen­tre, home PD ther­apy is an ap­pro­pri­ate treat­ment op­tion for pa­tients who live in re­mote ar­eas. It can mit­i­gate a pa­tient’s fi­nan­cial and health care in­equities and pro­vide the ad­di­tional ben­e­fit of re­duc­ing travel time. We be­lieve the same prin­ci­ples ap­ply here in Canada, and that Bax­ter can play a key role in im­prov­ing ac­cess and treat­ment for re­mote dial­y­sis pa­tients.

Our mis­sion of “Sav­ing and Sus­tain­ing Lives” has been trans­formed by tech­no­log­i­cal in­no­va­tion. The phe­nom­e­nal changes of the past two decades, es­pe­cially in health care, have re­cal­i­brated the mind­sets of many com­pa­nies, in­clud­ing Bax­ter, as we ad­dress both the op­por­tu­ni­ties and chal­lenges of in­creased con­nec­tiv­ity—in­clud­ing data pro­tec­tion and pa­tient pri­vacy. Com­pa­nies, hos­pi­tals and gov­ern­ments will have to work to­gether to ad­dress reg­u­la­tions in this area to ef­fec­tively bring these new tech­nolo­gies to mar­ket and ul­ti­mately im­prove the over­all pa­tient ex­pe­ri­ence. As the ef­fi­cien­cies pro­duced by tele­health and home treat­ment trans­form not just the cur­rent re­al­ity of ESKD but the whole health care sys­tem, the greater pub­lic will ben­e­fit from re­duced gov­ern­ment costs at a time of sig­nif­i­cant fis­cal pres­sure from other sources.

In its 2009 obit­u­ary of Dr. Willem Kolff, who had died at 97 at his home in Penn­syl­va­nia, the New York Times said of his early wartime pro­to­type for the dial­y­sis ma­chine, “The de­vice was an ex­em­plar of Rube Gold­berg in­ge­nu­ity.” With the right com­bi­na­tion of col­lab­o­ra­tion and in­cen­tiviza­tion, the med­i­cal tech­nol­ogy in­no­va­tions of the next half-cen­tury will make the break­throughs of today seem just as cre­ative, and just as ob­so­lete.

Bax­ter Canada photo

Thanks to in­no­va­tions in med­i­cal tech­nol­ogy, many kid­ney pa­tients can now ben­e­fit from home-based dial­y­sis, in­clud­ing two-way con­nec­tiv­ity al­low­ing doc­tors and nurses to mon­i­tor the treat­ment re­motely and ad­just pre­scrip­tions in real time.

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