What is your current position?
Dr. Szczech: I am the director of nephrology research at the Duke Clinical Research Institute [DCRI, at Duke University Medical Center in Durham, N.C.] I also direct the DCRI’s safety surveillance/pharmacovigilance program. I am an associate editor for Kidney International—a job that I love—and previously served on The American Society of Nephrology’s public policy board and as chair of [the organization’s] dialysis advisory group.
The NKF is an organization focused on the needs of patients. I think the average health-care provider is largely unaware of the breadth of activities undertaken by the NKF on behalf of patients. These activities span the horizon from raising awareness at the community level regarding kidney disease and screening, to provider education, to [advocating] in Washington for issues that impact patients’ lives. In North Carolina basketball terms, the NKF’s bench is deep.As president, I see myself as helping to identify new issues that need to be addressed from clinical practice and helping to translate programs to continue to meet the needs of our patients in a constantly changing health-care environment.
What is the main goal you hope to accomplish as NKF president?
Dr. Szczech: There are a few areas that I’m interested in pursuing as president. Two, however, come specifically to mind.
First, I am fascinated by how physicians and all health-care providers learn. I am always startled to see how long it takes for a new finding or study to become adopted as a standard of care. This length of time has been estimated at more than 10 years and up to 17.I am truly impressed with how quickly the NKF DOQI [National Kidney Foundation Disease Outcomes Quality Initiative] guidelines—particularly with respect to the categorization of CKD—became adopted, assimilated, and applied by the renal community in something on the order of 6 or so years.
While it could be that they were among the first all-encompassing guidelines of their kind in nephrology, there is likely more to it than that. We need to understand more about the “whys” of this success and use those as lessons learned on the very positive side as we continue to educate our patient-care teams.
Second, I am interested in understanding the reasons why screening for kidney disease does not occur in all patients at risk both domestically and internationally. These reasons will likely vary considerably, sometimes focusing on limited resources, sometimes focusing on cultural views of health care as well as a variety of other issues. But it is only through the understanding of the specific issues in each area/country/continent that we can truly brainstorm on ways to screen, prevent, find, and treat kidney disease.
Why are these goals of particular importance to you?
Dr. Szczech: These goals are important to me because I truly believe that we—not just as physicians but as people—have an ethical responsibility to make our world just a little better than it was when we came into it. I want to add my piece of the puzzle in this way.
In what areas do you hope to see rapid progress?
Dr. Szczech: In terms of research and clinical practice taken together, my hope is that we will see data that will translate into policy regarding how complex benchmarks of care should and need to be. Clearly outcomes for our patients have improved dramatically since the “know your number” campaign in the 1990s. And to the credit of the renal community, this wasn’t due to a “pay for performance” model of care, but rather simply our desire to do the very best for our patients. We identified benchmarks to the best of our abilities and implemented them with lightning speed.
But it is likely time to ask and answer the question, “Does one size truly fit all?” Using anemia as an example, I think we are all aware of the controversies surrounding hemoglobin targets and the results from the CHOIR [Correction of Hemoglobin and Outcomes in Renal Insufficiency], CREATE [Cardiovascular Risk Reduction by Early
Anemia Treatment with Epoetin Beta], and TREAT [Trial to Reduce Cardiovascular Endpoints with Aranesp Therapy], trials. Our challenges are to figure out how to apply these complex messages for subgroups such as those with and without diabetes, and then to similarly “question baseline assumptions” with the other easy-to-apply “threshold” benchmarks of care.
What is your stance on Medicare’s proposed bundling of payments for dialysis-related services and medications?
Dr. Szczech: The bundling of dialysis-related services is complex. And by the time this article is published, there may be considerably more available from CMS [Centers for Medicare and Medicaid Services] on the rule for its implementation. My approach to this is focused on the patient perspective and motivated by two well-known principles: What is the greatest good for the greatest number, and the desire to do no harm. In the latter I mean the desire not to change services and worsen outcomes that we already wish were better.
But having said that, there are too many aspects of nephrology that are not guided by trials to truly identify the superior treatment. Where superior treatment is identified, care should not be changed. But where it has not been identified, can we alter best practices and maintain or improve outcomes? The only way to know that is with the careful continued collection of data at a patient level.I believe that for the bundle to truly be effective in achieving the two principles that I gave, a solid commitment to data-gathering on the established benchmarks as well as morbidity and mortality and particularly patient satisfaction with care needs to be made. The latter is particularly important.So in short, if the bundle can provide the greatest good for a greater number without affecting outcomes or quality, no one can say it isn’t a good thing. But the key will be data analyzed in a timely manner.