Wednesday, November 9, 2011

Having standards of care in dialysis units

I have recently been interacting with a nephrologist of Indian origin who returned to India from the UK. During my discussions with her, I found that in nephrology settings in the UK (and in most of the US, Canada and possibly Australia and other 'developed' nations as well), they have standards of care that are well documented for all the common stuff related to dialysis patients.

For example, these are the blood tests you do every month. If the hemoglobin falls below some value, you start the patient off on Darbepoetin. No other type of Erythropoiesis Simulating Agents, mind you. Only Darbepoetin. And the dose would also be fixed. If the hemoglobin rose above some value, then you reduce the dose to this much and above this value, you stopped it altogether.

You had the basic rules for almost everything. What basic medication types must all patients on dialysis take? For example, most would be put on Phosphorus binders unless there was a compelling reason not to.

This is very different from the way medicine is practiced here, in India. Here it is very individualistic. And no, I am not referring to the patient! Everything depends on the doctor treating you. If your blood tests shows some value and you take it to your nephrologist, the way he would react could be totally different from the way the nephrologist of the dialysis patient on your neighbouring bed in the dialysis unit does!

While I agree to those that might argue that medicine is a very subjective thing and every patient is different, I find it difficult to see why the basics must be different. I interact with a lot of dialysis patients at NephroPlus and since we get patients from multiple nephrologists, I find that most of them are on very different treatment regimens for the same condition. It cannot be that different.

With some of the basics being determined by maybe, a panel of experts in advance, the nephrologists can actually focus on the more difficult challenges presented by patients. They could, without thinking too hard, instinctively react to the fundamental problems and spare their thinking time for peculiar problems faced by some patients.

There is one more advantage with this approach. Any new developments can be incorporated into these standards more uniformly and early on and not be prevented from reaching the patient simply because his or her doctor does not read up on the internet that often.

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