This weekend my wife and I visited some friends in Santa Barbara who are supporters of The Music Academy of the West. The Academy was founded by a group of artists and patrons in 1947 to “…aid in the development of gifted young classical musicians through advanced study with accomplished faculty artists.…” The Academy has evolved and now has its own campus where each summer more than 130 fellows participate through a combination of personal instruction, educational programs and live performances before small or large audiences. Guest faculty includes some of the icons of the music world, such as vocalist Marilyn Horne, opera legend Kiri Te Kanawa, violinist Gil Shaham, pianist Ingrid Fliter, and percussionist Colin Currie. Underlying it all is a strong culture of mentoring, as there is in training for a professional music career even while in school.

Participating students are experiencing this incredible summer experience while on hiatus from New England Conservatory, Juilliard, The Cleveland Institute of Music, Manhattan School of Music, Eastman School of Music and many other prestigious institutions. As I read through each student biography, I was struck by the fact that not only was the person’s school listed, but the key teacher with whom each student worked was identified as well. Mentoring. I had a chance not only to listen to solo, ensemble and orchestra performances, but also to talk to some of the students about their dreams for the future. There was a sense of wonder, of anticipation, of passion about the career for which they were preparing that inspired me. But it also made me think about my own career and the future of nephrology.

This was not the first time I was introspective about the need to re-examine nephrology as a discipline; to rethink how we attract the best and the brightest to the specialty and create opportunities for young doctors to see why nephrology, and improving the lives of kidney patients, is a noble, desirable career. In 2004 my colleagues and I published the results of a survey we took of 67 fellows participating in an advanced perceptorship in nephrology.¹ We found that exposure to hemodialysis and peritoneal dialysis was pathetic, with 50% of fellows reporting fewer than three months of exposure to in-center hemodialysis ICHD, often without didactic sessions or regular attending rounds) and 25% no exposure at all to peritoneal dialysis. This mirrored concerns expressed by many more than 10 years previously. ^2-4

Well, here we are, another 8 years later and has the situation improved? Three recent articles address this issue. Merighi et al. attempted to study the relationship between nephrology training experience and subsequent clinical practice. ⁵ Using a national survey, data from 2010 provided insights into the experience of over 600 nephrologists. Nearly 40% of respondents answered they did not feel well prepared for the care of dialysis patients at the end of their fellowship. In addition, although over 90% of dialysis patients in the US utilize ICHD, only 6% of the nephrologists surveyed would choose this modality for themselves.

Is this just a problem with training programs or is it a problem with the expectations residents have as they consider nephrology as a career? Shah et al. have tried to address this question in a fascinating study published recently. ⁶ Over 50% of the time nephrology was chosen prior to the second year of medical residency training, in half of these individuals during medical school or before. While the majority chose nephrology because of the interesting subject material, only 65% reported that mentoring or a role model was influential in the decision. A disappointing 64% were extremely or very satisfied about their career choice; however, the most common reason for high levels of satisfaction was mentoring.

So, how can the torch of nephrology be brightened, enhancing interest in the specialty, attracting the best and the brightest who can drive innovation in outcomes for our patients? Jhaveri et al. have proposed an interesting elective experience for medical residents that is an important step in the right direction.⁷ While there are many creative components to this approach, enhanced mentoring is an important component.

The theme is inescapable: if we really want to attract the nephrologists we would like to care for our families and ourselves, we need to focus on role models and mentors who are passionate about nephrology, about service to patients and about innovating to improve outcomes. If we can instill these cultural values in young physicians early in their career decision-making process, we can perhaps begin to build the discipline of nephrology to new greatness.

As Robert Frost said,

“I am not a teacher, but an awakener.”

It is incumbent on all of use to awaken the passion in students and colleagues to build the discipline our patients deserve.

Plutarch, over 2000 years ago, said it best:

“The mind is not a vessel to be filled, but a fire to be kindled.”

Striving to bring quality to life,
Allen R. Nissenson, MD

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1. Nissenson AR et al. Improving Outcomes in CKD and ESRD Patients: Carrying the Torch from Training to Practice. Semin in Dial 17:380, 2004.
2. Fine LG. A Proposal to Improve the Attractiveness of Nephrology as a Subspecialty Choice for Residents in Internal Medicine. Am J Kidney Dis 15:302, 1990.
3. Nissenson AR. Morbidity and Mortality of United States Dialysis Patients. The Legacy of Inadequate Nephrologist Training? Semin in Dial 5:277, 1992.
4. Kimmel PL et al. Effectiveness of Renal Fellowship Training for Subsequent Clinical Practice. Am J Kidney Dis 18:249, 1991.
5. Merighi JR et al. Insights into Nephrologist Training, Clinical Practice, and Dialysis Choice. Hemodial Internat 16:242, 2012.
6. Shah HH et al. Career Choice Selection and Satisfaction among US Adult Nephrology Fellows. www.cjasn.org Vol 7 September, 2012.
7. Jhaveri KD et al. Enhancing Interest in Nephrology Careers During Medical Residency, in press. http://dx.doi.org/10.1053/j.ajkd.2012.04.020.

In previous blogs I have talked about the highly fragmented care our patients receive, and how this leads to poor outcomes. This comes as no surprise to any busy nephrologist who struggles to juggle the multiple renal and comorbidity-related issues for these complex and fragile patients.  Most advanced CKD/ESRD patients are seeing 3- 4 additional physicians including a primary care doctor and multiple specialists. The ability of the nephrologist to know what is happening, in real time, is nearly impossible in the current care paradigm.

Within the dialysis facility there is a reasonable level of sophistication in the electronic capture, analysis and reporting of relevant clinical data to the nephrologist. Dialysis providers have developed systems that capture clinical and billing data and such information is increasingly becoming available to nephrologists not only in the dialysis facility but through security-protected web portals.

This is all fine, and some systems are more robust than others, but the real problem remains that only a fraction of the healthcare received by these patients takes place in a dialysis center. There is a crying need to have a truly integrated electronic health record (EHR) so that the care delivered by all relevant physicians, at all sites of care, including hospitals, will be available to the nephrologist in real time.

Now, adding the fact that Nephrologists providing dialysis care may have up to 85% of their patients on Medicare, the failure to implement “meaningful use” of a certified EHR in their practices sets them up to lose revenue due to reimbursement penalties imposed by the government.

Because of the complexity of nephrology practices and the diversity of their daily workflow, a nephrologist would be hard pressed to take a cookie cutter EHR “off the shelf” and expect that it will not only help them avoid reimbursement penalties but actually optimize the care of their patients.

There is good news here – some dialysis providers have decided to throw their hats into the ring and develop nephrology-focused EHRs. The key to nephrology-focused EHRs is that they have been created with the specific needs of nephrologists in mind. At least one of the nephrology-focused EHRs on the market integrates data from dialysis facilities into the nephrologist’s office EHR system to manage patients with ESRD. Such systems are also capable of capturing data in the office on CKD patients in a way that covers the continuum of an individual patient’s renal disease progression. If ACOs become a reality, the EHR that has the flexibility to truly integrate all relevant data as it becomes available, will be better positioned to close the loop – optimizing the delivery of patient care, as required by CMS for any approved ACO.

Bringing an EHR into the nephrology office is to some a daunting task, requiring large capital expenditures and technical expertise. Dialysis providers developing such systems and commercial vendors of generic EHRs being marketed to nephrology groups need to have the flexibility to work collaboratively with nephrology practices to address these issues to help ensure that the practice realizes the full potential of their chosen EHR  to improve care for patients and ease the administrative burden. If this can be done, nephrology patients will receive better care, and integration of care will be much more likely to accelerate.

As clearly stated by President Bush and President Obama:

“We need to reduce costs and medical errors with better information technology.”
President George W. Bush;  State of the Union Address;  January 23, 2007

“Our recovery plan will invest in electronic health records and new technology that will reduce errors, bring down costs, ensure privacy, and save lives.”
President Barack Obama; Address to Joint Session of Congress; February 24th, 2009

I look forward to your comments, until next time.

Striving to bring quality to life,

Allen R. Nissenson, MD

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Recently CMS convened a series of technical expert panels (TEPs) that were charged with recommending new clinical performance measures (CPMs) that could be submitted to the National Quality Forum (NQF) for endorsement.  As a member of the fluid management TEP I was able to follow the process from start to finish, and we should all be concerned about the process and the way we need to drive better quality for our patients.

The purpose of a CPM is to change behavior on the part of a practitioner.  That is, the CPM is derived from rigorous evidence in the literature, and is then constructed to set a target for a particular outcome based on the evidence.  For example, if best evidence suggests that patients have better survival with Kt/V≥1.2, the CPM would be the fraction of patients achieving this goal, and targets would be set based on current performance and projections of what should be desirable and achievable.

When the four TEPs completed their work, however, it became clear that the lack of rigorous evidence in the literature severely limited what CPMs could be based on solid evidence.  Despite this fact, and the recommendations of a separate data TEP- a group that opined on the availability of the data needed to calculate performance on each CPM proposed- that there were significant gaps in this area, 44 measures were forwarded to NQF for consideration.  A mere handful were endorsed since NQF has an appropriately high bar that CPMs must meet, particularly regarding quality of the evidence base, before they will be endorsed.

Many of my colleagues who participated in the process expressed disappointment or even outrage that the work of experts could be rejected by NQF.  It was clear to me, however, that since CPMs are used by regulators and payers and others to judge the performance of providers it is essential that such measures truly are based on evidence, and unfortunately many of ours were not or the evidence was scant and weak.

Thus the conundrum- does the lack of evidence that meets CPM standards mean that we are now paralyzed in driving the quality agenda forward?  I think we need to step back and think more clearly about the difference between measuring quality for accountability purposes and driving quality improvement for patients.  This to me is best understood using the OJ Simpson analogy.  As many of you will recall this renowned football player was accused of brutally murdering his wife and her friend.  Mr. Simpson was acquitted in the criminal case but lost in a civil case brought by the victim’s family.  In the former, to be convicted in criminal court there needed to be proof beyond a reasonable doubt while in the latter a preponderance of the evidence was sufficient.

We need to ask ourselves, although CPMs need to meet the “proof beyond a reasonable doubt” standard, quality improvement initiatives do not, in my view.  The art of medicine mandates that clinicians make their best judgment, based on whatever evidence is available, and on the balance between risk and benefit, on what should be tried and what shouldn’t.  This approach should be applied not only to the care of individual patients, but to populations as well.  Each of us would be wise to review the 44 CPM recommendations that came out of the TEPs and consider how to apply them to our dialysis populations- they may not meet the proof beyond a reasonable doubt standard, but if implemented they will do more to help improve patient outcomes than will waiting for the next big randomized controlled trial.

I look forward to your comments, until next time.

Striving to bring quality to life,

Allen R. Nissenson, MD

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I was in Washington, DC last month at the DaVita Board of Director’s meeting. My presentation to the Clinical Performance Committee of the Board was very upbeat—2010 was another great year for our patients with improvements in most intermediate outcomes, and continued improvement in survival rates.  Some of the clinical outcomes were truly spectacular; day 90+ catheter rate has fallen 27% since 2007 and influenza vaccinations reached 90% in the first quarter of 2011. I was very proud that our DaVita teams, caregiver teammates, Medical Directors, attending physicians, and all of the great support people in the field and at corporate, not only collaborated to make this happen, but were able to celebrate these remarkable achievements.

I was then able to present some of the data from our Seabiscuit’s program, the systematic approach to identifying chronically underperforming facilities based on clinical scores on the DaVita Quality Index (DQI)- these are facilities in the lowest 20% of DQI scores for at least 6 months.  As we presented at ASN last year, DQI a composite quality score, is a powerful predictor of facility level mortality and hospitalizations. Remarkably, the vast majority of the Seabiscuit’s facilities significantly improved their scores by intensely focusing on the underlying cause of their poor performance, usually the lack of facility leadership, such as a weak Facility Administrator or Medical Director, or both. I somewhat glibly stated to the Board that the key to improving these facilities had generally been bringing in new leadership; then one of the Board members, someone without any clinical background, asked a marvelous question. “What do these new people say they have done to improve the quality of care in the facility?”  Of course this is exactly what we should be asking so that we can share these pearls of information with all of our facilities.  I couldn’t answer the question, however, since we hadn’t asked it.

What is the “secret sauce” that makes a dialysis facility great? Is it clinically knowledgeable teammates, low staff turnover, a true team mentality and work ethic focused on the patient and the patient experience?  We intend to find out by going back to the facilities that were improved by focused, corrective action and asking them those questions. However, in the meantime, are anxious to hear from others about their sense of what it takes to be the best.

I look forward to your comments, until next time.

Striving to bring quality to life,

Allen R. Nissenson, MD