Nocturnal dialysis
A slower dialysis flow rate and blood flow rate means a gentler dialysis with fewer complications related to rapid fluid loss. This can result in an improved patient sense of well-being and less feeling of being “washed out,” and is especially beneficial to patients who are working, active or would enjoy the advantages of dialyzing at night. Nocturnal dialysis programs give nephrologists additional options for their patients, and are truly responsive to the Institute of Medicine’s call for patient-centered care.
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Paradigm shift
The current paradigm for CKD and end-stage renal disease (ESRD) care urgently needs revisiting to address the lack of coordination among the many physicians and sites of care involved in overall patient management.
Considerable experience already has been gained in the area of disease management in this population. The application of advanced care management to patients with kidney disease, in collaboration with nephrologists, has led to improved clinical outcomes and constrained costs of care. By anticipating adverse outcomes, and preventing those where proactive interventions are possible, the quality of care improves dramatically.
A key to the success of all of these approaches is a robust information system. Data is essential to the design, execution, and evaluation of these key approaches to improving patient care. In the near future, fully electronic medical records and personal health records, integrated electronically from all sites of care (dialysis facilities, hospitals, nephrologists’ offices), will be developed and will greatly improve the efficiency and accuracy of care.
To achieve success with the innovative programs outlined above, the kidney-care community must maintain a credible and increasingly unified presence in Washington, D.C., because fair and appropriate funding is essential.
Right now, the federal government’s ESRD program takes care of fewer than 1% of Medicare beneficiaries but consumes about 7% of Medicare dollars. And the number of new ESRD patients is rising steadily. Congressman Pete Stark (D-Calif.) is proposing cutting reimbursement and moving to a bundled service in two years with an additional large reimbursement cut.
Educating the Congress and regulators is simply part of being a leader in the kidney-care community. There are models for how such leadership might be organized. DaVita, for example, has been in the forefront of efforts to educate regulators and legislators about the burdens carried by nephrologists, other caregivers, and patients.
DaVita supported the establishment of Kidney Care Partners (KCP), the kidney community coalition that has succeeded in attracting the major groups representing every facet of kidney care. DaVita remains a firm believer and supporter of this vital group. KCP has enabled a more coherent presentation of the community’s issues and demonstrated the ability to influence public policy more than anytime in the community’s history. Compromise and consensus building is never easy, so we best bear in mind Benjamin Franklin’s admonition that “we must hang together or we will most certainly all hang separately.”
Moreover, DaVita has encouraged patients (through DaVita Patient Citizens) and nephrologists (through the DaVita Nephrology Alliance) to facilitate involvement of both groups in the political process. The renewed focus on kidney disease by Congress and Medicare—including bundled payment systems, anemia management and P4P—provides an enormous opportunity to define the future rather than just passively accept the future that others design.
The anemia management debate has been a classic example of incomplete and misleading information that prompts policymakers to contemplate seriously flawed policies with potentially devastating unintended consequences. Yet even this highly flawed debate has in fact provoked some legitimate and important questions about anemia care, and we are eager to work on them with calm professionalism and responsible transparency. KCP, DaVita Patient Citizens, and DaVita Nephrology Alliance all continue to add meaningful information to this discussion.
Finally, if successful, we can foresee a shift in renal care such that the focus is on early CKD detection. Patients would be enrolled in educational and care-delivery programs through CKD clinics, with care delivered by nephrologists working side-by-side with other teammates, including nurse practitioners, dietitians, and social workers. Their goal would be to slow progression of CKD, and identify and treat modifiable CVD risk factors and CKD complications, including anemia, bone disease and malnutrition.
With this approach, patients will be healthier as they approach the need for renal replacement therapy, which will be coordinated with appropriate placement of access for dialysis (vascular or peritoneal), and discussions about preemptive transplantation. Once on dialysis, advanced care management for patients will continue so that fragmentation of care is avoided. Medications will be tracked through facility-based pharmacy programs. Vascular access care will be provided through dedicated outpatient vascular access centers, and home dialytic modalities will be encouraged for appropriate patients through well-organized home dialysis programs.
The nephrology community that works with DaVita has already achieved impressive clinical outcomes. The public data reflect that together we are among the leaders in many clinical areas.
But the time has come to be bold in the pursuit of more integrated kidney care in America. The challenge of pursuing this goal is made more difficult by the need to ensure that reform does not put the financial health of nephrology practices at risk, nor threaten our goal of ensuring a high level of personal fulfillment for nephrologists that is not diluted by the relentless burdens of day-to-day practicing in the current environment.
Mr. Thiry is chairman and CEO of DaVita. Dr. Nissenson is professor of medicine and director of the dialysis program at the DavidGeffenSchool of Medicine at the University of California at Los Angeles. He is also a consultant to DaVita.
