DaVita Medical Insights

Acute Kidney Injury Patients Now Receiving Dialysis in an Outpatient Setting

 

This January, the Centers for Medicare & Medicaid Services (CMS) gave dialysis centers the ability to provide dialysis services to acute kidney injury (AKI) patients. The goal was to allow hospitalized AKI patients who needed dialysis, but were otherwise “stable,” to return home for convalescence and receive dialysis in an outpatient setting. I applaud CMS’ decision. It is both financially and clinically responsible, given the safety and infectious risks within hospitals. There are many unknowns on how the system will be structured—but the following domains will likely be influenced.

1. Patient Load in Dialysis Centers

As long as admission criteria are met, AKI patients from a variety of care settings—such as hospitals, rehab centers and skilled nursing facilities—will likely be accepted for outpatient treatment. Considering historical data, there may be an increase of one to five patients per center. This number may be an underestimate if hospitals pressure nephrologists to quickly discharge AKI patients or if the diagnosis of AKI is broadened to encompass ultrafiltration failures due to conditions such as congestive heart failure or cirrhosis.

2. Coding

It is important to stress that these patients are not end stage renal disease (ESRD) patients; an AKI diagnosis is an entirely different clinical diagnosis, and as such, has different clinical care requirements. Nephrologists, therefore, may not utilize MCP codes. Rather, they may, per CMS directives, use the hospital codes for acute dialysis based on the work they perform when caring for these patients in the outpatient center.

3. Regulatory and Evaluations

Patients with AKI can require more-frequent treatments, but this is usually when they are hospitalized and are hypercatabolic and unstable. Data show that AKI dialysis prescriptions are often three times per week and, in fact, sometimes two per week. This may be due to the patient recovering renal function. The ESRD Conditions for Coverage were last updated October 2008 and AKI was not included, so there is no regulatory direction or clarity on this treatment. That said, dialysis center medical directors are responsible for all patients and, by inference, will be responsible to the AKI patients. Since much is unknown about outcomes for AKI patients, they are not included in the CMS Quality Incentive Program.

AKI is a broad-based, non-specific diagnosis encompassing many other primary disease processes. It will be important to monitor this patient cohort, much like we do with ESRD patients, to better understand: What are the underlying etiologies of the AKI? What are the recovery rates and when does that occur? What is the burden for care for these patients, for nursing and nephrologists? Does allowing care in the outpatient setting offer a survival advantage or decreased hospital readmissions? What is the actual cost of caring for them in the outpatient setting? As we have with ESRD patients, I expect we will soon better understand these patients, which will allow providers to better tailor care to their needs.

Note: Some of the content within this article has been republished with permission from Nephrology News & Issues.

Robert Provenzano, MD, FACP, FASN

Robert Provenzano, MD, FACP, FASN

In addition to his role as vice president of medical affairs at DaVita Kidney Care, Robert Provenzano, MD, is a clinical professor of medicine at Wayne State University School of Medicine in Detroit, where he earned his medical degree. He completed his fellowship training at Henry Ford Hospital and served as the chief of the nephrology, hypertension & transplantation section and director of nephrology research at St. John Hospital and Medical Center in Detroit. Dr. Provenzano is former president of the Renal Physicians Association and chair of the National Kidney Foundation of Michigan. He is also former CEO of St. Clair Specialty Physicians, PC, a multistate nephrology practice. He has published extensively on kidney care business models and is the chief medical officer of Nephrology Practice Solutions (NPS), a national kidney care management company affiliated with DaVita that oversees owned and managed practices.