CORRESPONDENCE
200 showed destructive osteoarthropathy from C. to C6 (Fig 1). The odontoid was surrounded by soft tissue with notable spinal chord deviation with low-intensity signal in T.- and Tr weighted sequences enhanced by gadolinium. Despite immobilization of the neck, the clinical course was unfavorable and the patient died from gastrointestinal bleeding in March 1991. Postmortem biopsy of the cervico-occipital hinge showed congophile deposits. Immunofluorescence was negative for kappa, lambda, and protein A but positive for fJ2m. In the two cases reported by Allard et ai, the patients were on maintenance hemodialysis for 15 and 17 years, respectively. In our case, this amyloid arthropathy occurred after only 6 years of hemodialysis. This is unusual. Arthropathy was predominant in the cervico-occipital hinge, with little or no preceding peripheral symptoms and resulted in rapidly progressive neurological symptoms. Two similar cases, not mentioned by Allard et ai, with severe neurological symptoms have been previously reported, both associated with B2-microglobulin deposition. One relates a quadriparesis due to diffuse extradural amyloid deposits (Allain et al), 2 the other a great occipital nerve neuralgia (Kessler et al).3 The risk of cervical myelopathy in hemodialized patients is of poor prognosis, in part because of the high mortality of surgical treatment. Physicians should be particularly watchful when cervical pain or neurological disturbances occur in a hemodialyzed patient.
CAN WE REGULATE THE QUALITY OF CARE To the Editor: I read with interest the June 1992 article "Can we regulate quality of care? The case of dialysis in Connecticut," by Brown, Smith, and Sindelar and the accompanying editorial by Richard Rettig. From the work I did for my 1991 Masters thesis I can provide data verifying that the cost of delivering maintenance dialysis in Connecticut far exceeds the composite rate reimbursement (Fig 1). I also show that staff costs were in large part responsible for the high costs (Fig 2). These charts represent per treatment costs as a percentage of per treatment
BAIDOE~OAT 1=======Ii~;-------l 81
Department of Rheumatology
Laure-Helene Noel Malek Dhib Robinson Joannides Sylvie GejJroy-Josse Michel Godin Department of Nephrology CHU Rouen-France
REFERENCES I. Allard JC, Artze ME, Porter G, et al: Fatal destructive cervical spondyloarthropathy in two patients on long term dialysis. Am J Kidney Dis 19:8 1-85, 1992 2. Allain TJ, Stevens PE, Bridges LR, et al: Dialysis myelopathy: Quadriparesis due to extradural amyloid of B2 microglobulin origin. Br Med J 296:752-753, 1988 3. Kessler M, Netter P, Grignon B, et al: Destructive B2 microglobulin amyloid arthropathy of the cervi co-occipital hinge in a hemodialysed patient. Arthritis Rheum 33:602603,1990
reimbursement. My thesis also shows the staff costs are related to the high staff/patient ratio, the impact of the widespread nursing shortage, and state statutes on patient care technicians. As both American Journal ofKidney Diseases articles point out, according to the state health code patient care technicians are not allowed in freestanding units and must be directly supervised by a registered nurse in hospital units. Because the sample of costs used to determine the composite rate is national, where technicians are routinely used, the health code is preventing Connecticut facilities from making the cost goal. Bridgeport, the only unit to deliver care within reimbursement, at that time used a staff mix that included care technicians. It is clear that Connecticut's dialysis facilities cannot keep their costs within the federal payment. What is not clear is
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Fig 1. Connecticut dialysis facilities. Total cost as a percent of composite rate.•, Percent. Data source: 1989 HCFA year-end cost reports.
IU"'OIlD ROCKVILLE OANIUIIT 81. MARYI HEW IAtTAIN NORWICH TORRINOTON lOT IINAI 'AU · N+H. HARHORD
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Fig 2. 1989 staff cost as a percent of composite rate. D, Percent. Data source: 1989 HCFA year-end cost reports.
CORRESPONDENCE
201
the effect on quality of the state regulations. My personal experience dialyzing in Connecticut facilities for more than 10 years. as well as elsewhere, leads me to conclude that Connecticut uses a service model rather than an efficiency model. However, for the stable patient, the provided levels of staffing and skills are not usually necessary and may even disable by creating a sick-room atmosphere. Rather than regulating to mandate highly skilled staff, what is needed are regulations regarding equipment and faster adoption of new technology. For an objective evaluation of relative quality, I agree with the authors on the use of outcomes: mortality as they suggest, but also morbidity and patient satisfaction. The state could evaluate facility-specific adjusted mortality compared with regional and national figures simply through the use of Network adjusted mortality data. As a measure of morbidity. the fistula/graft procedure rate would make a good marker. Although it is widely believed that the Certificate-of-Need (CON) is a major barrier to growth. this assumption needs to be questioned. It is said that the process is long and costly. In fact, it takes at least 18 months to approve the CON for a new unit and 6 months for expansion of an existing facility. The costs result from expensive health and legal consultants necessary to prepare the proper paperwork. The Commission on Health and Hospitals, which issues the CON. assures me they are interested in receiving and approving applications for additional dialysis space. Perhaps steps should be taken to shorten and simplify the process, as in New York State where "need" was eliminated as a CON criteria.
As to the seriousness of the access problem, in February 1992 28 patients in the New Haven area waited for space, enough to fill an entire new unit. These people were either being dialyzed as hospital acute patients or traveling by ambulance, at Medicare expense, at least an hour each way to dialyze in Danbury. Torrington. and Enfield. Hartford Hospital Dialysis also had a waiting list, with patients farmed out locally. From the southern part of the state. a Bridgeport patient rode three times weekly to Torrington by taxi. at Medicaid expense. Finally. neither article mentioned the role of the Network in guaranteeing access. From their inception Networks had the charge to "assure a sufficient number of dialysis and transplant facilities are available to guarantee patients access to care and to various treatment modalities." Their responsibility should be more than acting as a clearinghouse for treatment space. Furthermore. the Network should be wide open to patient grievances during this period when there is little chance of a facility transfer. Perhaps all those governing the delivery of dialysis care here need to think about what Richard Rettig told the American Association of Kidney Patients at their 1991 annual meeting: "the ESRD program is an entitlement for patients not for facilities." Carole Robbins, MPH Mt Sinai Hospital Dialysis Hartford. CT
Reply: The letter from Carole Robbins, MPH. makes clear that a cost burden is imposed on dialysis units in Connecticut by state health code regulations. This cost burden reinforces the access limits caused by state Certificate-of-Need, health code regulations, and aggressive enforcement of regulations. If quality is increased, it is because rationing is imposed on a federal entitlement program by well-intentioned but misguided state laws and regulations.
The appropriate response is not more regulation, as Ms Robbins suggests, but less. Connecticut should eliminate the regulatory and financial barriers that impose higher than needed costs on treatment facilities and are creating serious access limitations to life-saving treatment. Richard A. Rettig, PhD Institute of Medicine National Academy of Sciences Washington, DC
200 showed destructive osteoarthropathy from C. to C6 (Fig 1). The odontoid was surrounded by soft tissue with notable spinal chord deviation with low-intensity signal in T.- and Tr weighted sequences enhanced by gadolinium. Despite immobilization of the neck, the clinical course was unfavorable and the patient died from gastrointestinal bleeding in March 1991. Postmortem biopsy of the cervico-occipital hinge showed congophile deposits. Immunofluorescence was negative for kappa, lambda, and protein A but positive for fJ2m. In the two cases reported by Allard et ai, the patients were on maintenance hemodialysis for 15 and 17 years, respectively. In our case, this amyloid arthropathy occurred after only 6 years of hemodialysis. This is unusual. Arthropathy was predominant in the cervico-occipital hinge, with little or no preceding peripheral symptoms and resulted in rapidly progressive neurological symptoms. Two similar cases, not mentioned by Allard et ai, with severe neurological symptoms have been previously reported, both associated with B2-microglobulin deposition. One relates a quadriparesis due to diffuse extradural amyloid deposits (Allain et al), 2 the other a great occipital nerve neuralgia (Kessler et al).3 The risk of cervical myelopathy in hemodialized patients is of poor prognosis, in part because of the high mortality of surgical treatment. Physicians should be particularly watchful when cervical pain or neurological disturbances occur in a hemodialyzed patient.
CAN WE REGULATE THE QUALITY OF CARE To the Editor: I read with interest the June 1992 article "Can we regulate quality of care? The case of dialysis in Connecticut," by Brown, Smith, and Sindelar and the accompanying editorial by Richard Rettig. From the work I did for my 1991 Masters thesis I can provide data verifying that the cost of delivering maintenance dialysis in Connecticut far exceeds the composite rate reimbursement (Fig 1). I also show that staff costs were in large part responsible for the high costs (Fig 2). These charts represent per treatment costs as a percentage of per treatment
BAIDOE~OAT 1=======Ii~;-------l 81
Department of Rheumatology
Laure-Helene Noel Malek Dhib Robinson Joannides Sylvie GejJroy-Josse Michel Godin Department of Nephrology CHU Rouen-France
REFERENCES I. Allard JC, Artze ME, Porter G, et al: Fatal destructive cervical spondyloarthropathy in two patients on long term dialysis. Am J Kidney Dis 19:8 1-85, 1992 2. Allain TJ, Stevens PE, Bridges LR, et al: Dialysis myelopathy: Quadriparesis due to extradural amyloid of B2 microglobulin origin. Br Med J 296:752-753, 1988 3. Kessler M, Netter P, Grignon B, et al: Destructive B2 microglobulin amyloid arthropathy of the cervi co-occipital hinge in a hemodialysed patient. Arthritis Rheum 33:602603,1990
reimbursement. My thesis also shows the staff costs are related to the high staff/patient ratio, the impact of the widespread nursing shortage, and state statutes on patient care technicians. As both American Journal ofKidney Diseases articles point out, according to the state health code patient care technicians are not allowed in freestanding units and must be directly supervised by a registered nurse in hospital units. Because the sample of costs used to determine the composite rate is national, where technicians are routinely used, the health code is preventing Connecticut facilities from making the cost goal. Bridgeport, the only unit to deliver care within reimbursement, at that time used a staff mix that included care technicians. It is clear that Connecticut's dialysis facilities cannot keep their costs within the federal payment. What is not clear is
~HCI'
'TA"'O~D
NO~WAUC
HAIIIT'OfIID
w.Tl.llleU'U'
NO~WICH
H •
Philippe Chassagne Lamia Ait Said Xavier Le Loet Pierre Deshayes
I1111111
"UDOE~ORT
INTAIH
IT IOA~YI OANIU.n' lIT IlMAI YALf • N H
TORRINOTON
:f
o
ST ""AHClS WATERBURY NORWALK
20.
L
Fig 1. Connecticut dialysis facilities. Total cost as a percent of composite rate.•, Percent. Data source: 1989 HCFA year-end cost reports.
IU"'OIlD ROCKVILLE OANIUIIT 81. MARYI HEW IAtTAIN NORWICH TORRINOTON lOT IINAI 'AU · N+H. HARHORD
20
4,
10
10
Fig 2. 1989 staff cost as a percent of composite rate. D, Percent. Data source: 1989 HCFA year-end cost reports.
CORRESPONDENCE
201
the effect on quality of the state regulations. My personal experience dialyzing in Connecticut facilities for more than 10 years. as well as elsewhere, leads me to conclude that Connecticut uses a service model rather than an efficiency model. However, for the stable patient, the provided levels of staffing and skills are not usually necessary and may even disable by creating a sick-room atmosphere. Rather than regulating to mandate highly skilled staff, what is needed are regulations regarding equipment and faster adoption of new technology. For an objective evaluation of relative quality, I agree with the authors on the use of outcomes: mortality as they suggest, but also morbidity and patient satisfaction. The state could evaluate facility-specific adjusted mortality compared with regional and national figures simply through the use of Network adjusted mortality data. As a measure of morbidity. the fistula/graft procedure rate would make a good marker. Although it is widely believed that the Certificate-of-Need (CON) is a major barrier to growth. this assumption needs to be questioned. It is said that the process is long and costly. In fact, it takes at least 18 months to approve the CON for a new unit and 6 months for expansion of an existing facility. The costs result from expensive health and legal consultants necessary to prepare the proper paperwork. The Commission on Health and Hospitals, which issues the CON. assures me they are interested in receiving and approving applications for additional dialysis space. Perhaps steps should be taken to shorten and simplify the process, as in New York State where "need" was eliminated as a CON criteria.
As to the seriousness of the access problem, in February 1992 28 patients in the New Haven area waited for space, enough to fill an entire new unit. These people were either being dialyzed as hospital acute patients or traveling by ambulance, at Medicare expense, at least an hour each way to dialyze in Danbury. Torrington. and Enfield. Hartford Hospital Dialysis also had a waiting list, with patients farmed out locally. From the southern part of the state. a Bridgeport patient rode three times weekly to Torrington by taxi. at Medicaid expense. Finally. neither article mentioned the role of the Network in guaranteeing access. From their inception Networks had the charge to "assure a sufficient number of dialysis and transplant facilities are available to guarantee patients access to care and to various treatment modalities." Their responsibility should be more than acting as a clearinghouse for treatment space. Furthermore. the Network should be wide open to patient grievances during this period when there is little chance of a facility transfer. Perhaps all those governing the delivery of dialysis care here need to think about what Richard Rettig told the American Association of Kidney Patients at their 1991 annual meeting: "the ESRD program is an entitlement for patients not for facilities." Carole Robbins, MPH Mt Sinai Hospital Dialysis Hartford. CT
Reply: The letter from Carole Robbins, MPH. makes clear that a cost burden is imposed on dialysis units in Connecticut by state health code regulations. This cost burden reinforces the access limits caused by state Certificate-of-Need, health code regulations, and aggressive enforcement of regulations. If quality is increased, it is because rationing is imposed on a federal entitlement program by well-intentioned but misguided state laws and regulations.
The appropriate response is not more regulation, as Ms Robbins suggests, but less. Connecticut should eliminate the regulatory and financial barriers that impose higher than needed costs on treatment facilities and are creating serious access limitations to life-saving treatment. Richard A. Rettig, PhD Institute of Medicine National Academy of Sciences Washington, DC
