Physician Case Load Linked to Death during Dialysis

Medical malpractice lawyers at Pintas & Mullins Law Firm highlight a recent observational study which found that higher caseloads for nephrologists lead to higher death rates in their hemodialysis patients. Patient mortality was about 2% higher for each additional 50 cases a physician took on.

The study was conducted at the University of California, Irvine, and published in the Journal of the American Society of Nephrology. Researchers also found that physicians with lower patient mortality also demonstrated better dialysis characteristics, such as longer sessions and increased dialysis doses.

End-stage renal disease care is extremely expensive and dangerous; sudden cardiac arrest is the most fatal complication that can occur while on dialysis, a risk that is heightened if a patient’s attending physician does not have sufficient time to monitor them. Each individual patient requires a unique dose and time allotment during dialysis, and if not enough attention is paid to these factors, the effects can be deadly.

Conversely, other studies have linked high case volumes for physicians to advantages in surgical and invasive procedures. Such examples include AIDS, sepsis, and acute myocardial infarction (heart attack) procedures, where experience and repetition is critical to a successful outcome. Care for end-stage renal disease, however, differs because the potential for complications is so individualized.

Of course, acquiring experience and knowledge is important for physicians, however hemodialysis requires a substantial amount of individualized management and communication with other team members, along with complex medical decisions that require more time to consider. Nephrologists with high caseloads may simply not have enough time to consider all these factors carefully for each patient.

The UC Irvine study used data from the U.S. Renal Data System to examine outcomes for over 4,000 hemodialysis patients in the Los Angeles metropolitan area. Specifically, researchers analyzed patients at DaVita dialysis clinics, and physicians with caseloads between 50 and 200 patients.

In total, more than 40 nephrologists were included in the retrospective study and ranked by patient mortality rate between the years 2001 and 2007. Physicians with the highest rates of patient mortality had average case loads of about 103, while those with lowest patient mortality had caseloads around 65. In fact, mortality risk consistently rose as caseloads increased above 50, plateauing around 140.

Other characteristics that put hemodialysis patients at an increased risk of death included being African American or Caucasian (Hispanics had the best survival rates), having diabetes, heart conditions or hypertension, being insured through Medicaid, and greater inflammation demonstrated by lower white blood cell counts.

These associations, however, may not be completely straightforward. For example, shorter dialysis sessions were linked to higher mortality rates and increased physician caseloads, which may be influenced by overcrowding or patient non-adherence to process, rather than physician aptitude. Other limitations include severity of illness and influence of socioeconomic status beyond insurance carrier (Medicaid vs private insurance). The study also did not differentiate between specific causes of death, number of provider visits per month, presence of nurse practitioners, or associations with academic centers.

It is worth noting that the study also did not detail the types of drugs administered during dialysis treatments. It has been proven that dialysis patients administered the products GranuFlo and NaturaLyte have significantly increased risks of mortality, due to the defective design and manufacture of these drugs. GranuFlo is given to balance acid and base in patients’ blood streams, however, the product often causes the blood to become too acidic, leading to heart problems and cardiac arrests.

Many dialysis centers used GranuFlo because it was cheaper to ship and store; it is made of dry acid powder, enabling the lower costs as most other dialysis products are liquid formulations. Powder forms are much more concentrated than liquid, however, and are converted by the body into higher levels of bicarbonate, leading to highly acidic blood. Due to increasingly high rates of death and injury associated with GranuFlo and NaturaLyte, the FDA issued a Class I recall of the product, the most serious type of recall, in 2011.

Dialysis lawyers at Pintas & Mullins Law Firm encourage anyone who was seriously injured during dialysis treatment, and particularly those administered GranuFlo or NaturaLyte, to contact a qualified medical malpractice attorney as soon as possible. You and your family may be entitled to significant compensation for any additional medical costs, lost wages, wrongful death, or emotional distress.

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