When I was a young faculty member at UCLA, I had heard about the Renal Physicians Association (RPA) but did not think there would be any reason to join. After all, this was a group that focused on payment issues for nephrologists, and how could that possibly be relevant to someone who was a salaried doctor, and at an academic health center? As I delved into my responsibilities at UCLA, however, and became responsible for overseeing the care of patients in a large dialysis program almost entirely dependent on Medicare for reimbursement, it started to become clear to me how critical it was to have a strong advocacy organization that could work with Medicare and Congress to craft the most appropriate, effective and fair public policy for the end stage renal disease (ESRD) program. In addition, as clinical nephrology practice was becoming more complex with the new appreciation for the scope of the chronic kidney disease (CKD) epidemic, the need for tools to assist nephrologists in delivering the highest-quality care increased dramatically. I saw the light, and the rest is history. I joined RPA, worked on committees, served on the board of directors (1993-2006) and eventually served as president (1999-2001).

The nephrologists who originally formed RPA were ahead of their time. They began to build important relationships with the Health Care Financing Administration (HCFA), now called the Centers for Medicare and Medicaid Services. This collaboration served all nephrologists and kidney patients well in the subsequent four decades, with key regulatory and legislative achievements focused on improving the lives of patients while ensuring that nephrologists’ interest were represented as well. As the organization matured it began to focus intently on driving quality in ESRD care, and in 1993 it developed the first clinical practice guideline in our discipline—addressing adequacy of dialysis—several years before the Disease Outcomes Quality Initiative was begun. The most recent guideline on appropriate initiation and withdrawal of dialysis has become a seminal resource for nephrologists, patients and families to assist in decision-making at the difficult time of transition to dialysis. Myriad tools to assist nephrologists in optimizing care for CKD and ESRD patients have also been developed and disseminated.

I am particularly proud of RPA’s accomplishments during my two-year tenure as president. The following are some of the highlights:

• RPA initiates Renal Fellows Workshop prior to annual meeting
• First nephrology practice benchmarking survey conducted and presented
• RPA launches corporate patrons program to engage in dialogue with industry supporters
• RPA publishes first edition of the Renal Physicians Guide to Nephrology Practice
• RPA convenes summit on chronic renal disease (with American Society of Pediatric Nephrology, American Society of Nephrology, and National Kidney Foundation)
• HCFA responds to RPA’s request for community input on a method to measure and report on quality of renal dialysis services with establishment of the ESRD stakeholders council
• RPA surveys randomly selected nephrology practices on expenses associated with the inpatient dialysis codes and the monthly capitation payment
• RPA offers mortgage-financing assistance to members for home purchases
• RPA publishes second clinical practice guideline on appropriate initiation and withdrawal of dialysis
• RPA launches third guideline on appropriate patient preparation for renal replacement therapy
• RPA publishes Capitation Models for ESRD: Methodology and Results—culmination of a two-year data-collection and -analysis effort supported by member contributions; risk-adjusted capitation rates and total spending for ESRD patient care
• Past RPA president Dr. Derrick Latos becomes chair of the Practicing Physicians Advisory Council (established by Congress in 1990 to advise the Health and Human Services secretary on regulations and carrier manual instructions that relate to MD services under Medicare/Medicaid)
• RPA launches patient safety initiative; convenes multistakeholder workshop
• RPA launches website; creates www.renalmd.org
• RPA testifies at Senate Special Committee on Aging in the ESRD program

I am very proud of what the organization accomplished during those years and subsequently, but now it’s time to focus on the future. The discipline of nephrology faces many challenges now and in the years to come: trainees’ waning interest in becoming nephrologists; continued downward pressure on reimbursement for nephrology procedures/activities; an increase in the number of employed physicians throughout healthcare; the rise of Accountable Care Organizations and other risk-taking, risk-sharing organizations; the increasing emphasis on value rather than volume in healthcare; federal budget constraints and pressure to restructure Medicare; a growing elderly, frail population with multiple chronic illnesses; etc., etc.

Some nephrologists are already throwing up their hands in despair, but my advice—which comes from years of watching the ESRD program grow and mature and from working with RPA—is to be a champion for our patients and our discipline. Helping strengthen RPA and being an active participant in the advocacy, public policy, and quality-of-care efforts is the best way to truly be a champion in nephrology.

As Muhammad Ali said,
Champions are made from something they have deep inside them—a desire, a dream, a vision.

HAPPY BIRTHDAY, RPA!

“July and August will be critical months to take our message to Washington: no more cuts for dialysis patients and their providers.”

The recent proposal from the Centers for Medicare & Medicaid Services (CMS) to cut reimbursement for dialysis treatments by 9.4 percent has made me think hard about where dialysis has been, where it is now and where it might be headed. When I began my internship and residency at Michael Reese Hospital in Chicago (now gone, unfortunately), the Medicare entitlement for dialysis had not yet been enacted. Michael Reese had a long connection with pioneers in dialysis dating back to the 1920s. During my internship I rotated on the nephrology service. We had converted a hospital room to a dialysis ward and built Kiil dialyzers each time we wanted to do hemodialysis. We created Scribner shunts for blood access, and each treatment was an exciting challenge to get through without hypotension, clotting or other misadventures. We also had more than 40 patients on intermittent peritoneal dialysis (IPD). They would be admitted to the hospital each week, have a peritoneal catheter inserted and receive 48 hours of IPD. As the intern on the service, I admitted each patient, drew blood and then ran a set of electrolytes in a dedicated lab on the ward. I prescribed the peritoneal dialysis regimen for the 48 hours based on the physical examination and laboratory values. The Medicare entitlement for dialysis was enacted in the first year of my residency, 1972, and implemented in 1973. It changed everything.

Read more…

Patients with ESRD are the most medication-burdened of all the chronically ill. They take an average of 8 to 10 different medications, consuming more than 20 pills per day. It is not surprising, therefore, that the ability of nephrologists, dialysis facilities and patients to manage these medications is a challenge. Patients often do not know what medications they are on, and the monthly “pill check”—usually a shoebox filled with medication bottles—is notoriously inaccurate (1). More importantly, it has been estimated that up to a third of hospitalizations among the frail elderly (which includes a significant number of ESRD patients), and nearly half of re-hospitalizations in this population, are related to medication errors or adverse reactions. Finally, because of the large pill burden, the high costs of some medications and the significant occurrence of adverse events, adherence to prescribed medications is suboptimal (2).

Integrated pharmacy services can help resolve many of these issues for ESRD patients, as recently demonstrated by Weinhandl et al (3). This study compared nearly 9,000 patients enrolled in the DaVita Rx full-service pharmacy program to more than 40,000 control patients not in the program. Read more…

We are seeing a continual increase in the number of US patients with CKD and ESRD. The epidemic of obesity, and resultant diabetes and hypertension, has not abated and will continue to swell the ranks of patients needing care from nephrologists. Add to this the incredible improvement in the survival rate of ESRD patients over the last decade and the extended availability of medical care to the uninsured thanks to the Affordable Care Act, and we are indeed on the brink of a tidal wave of kidney patients. These facts should be a wake-up call to health policy-makers, especially in light of the shocking statistics from the most recent Medical Specialties Matching Program (MSMP)(1). For appointment year 2013, MSMP indicates that nearly a quarter of nephrology fellowship programs had unfilled positions, the worst of all medical subspecialties. Only 25 percent of positions were filled by US graduates overall and only 21 percent of clinical nephrology positions are filled by US graduates—the lowest of any medical subspecialty. Read more…

Every March National Kidney Month comes around, and every March I wonder how it is that the eighth leading cause of death in this country still hasn’t achieved the public recognition and awareness level of other killers, like heart disease, cancer, stroke and diabetes. It seems we could save so many lives and avoid so much suffering if the general public knew even the most basic information about kidney disease and its risk factors.

But the somewhat frustrating truth is that when I talk about what I do professionally with nonmedical people, I frequently hear the question, “What’s dialysis?” People generally seem to know they have kidneys and know they’re important, but have no idea why.

There’s so much health-related information available—so many conditions clamoring for funding and recognition—that it may all be too much for the modern consumer to digest.  Frankly, there are so many ribbons representing advocacy for various disease states that no one seems to know which color goes with which illness anymore. For example, the ribbon for kidney conditions is green, but so are the ribbons for bipolar disorder, celiac disease, scoliosis, cerebral palsy and Tourette syndrome, to name a few. Read more…

My last blog used the infamous Rodney King episode in Los Angeles as the springboard for suggesting that integrating care—physicians, hospitals and patients working together—is essential to achieve the best clinical outcomes for the chronically ill while constraining the runaway costs of healthcare. A recent article in The New York Times (http://www.nytimes.com/2012/12/25/opinion/approaching-illness-as-a-team-at-the-cleveland-clinic.html?_r=0) makes it clear that this is not a theoretical concept. Physicians at one of the great healthcare organizations in the country, the Cleveland Clinic, have been forming focused teams that can mobilize to efficiently diagnose and treat a variety of illnesses, including neurological, cardiovascular, oncologic, urologic and nephrologic. Read more…

On March 3, 1991, an infamous event was caught on videotape in Los Angeles. Rodney King, a parolee and construction worker, was beaten brutally by Los Angeles police officers following a high-speed chase. After the video went viral the police officers were arrested and charged with assault and excessive force. Following the acquittal of three of the four officers on April 29, 1992, there were riots in Los Angeles, with 53 people killed and thousands injured. It was during the riots that Rodney King, the lightning rod for these events, asked, “Can we all get along?” Read more…

I am sitting here on Father’s Day and reminiscing about my father. He was born in 1919 into a struggling first-generation immigrant family in Chicago. Over the years he worked hard, as folks who lived through the Great Depression and World War II did in those days, and became a successful businessman. He taught me many things, but above all the importance of interpersonal relationships and the value, the imperative, of always treating everyone with respect and dignity—from your bosses to the housekeepers. This value serves me well, as it did him. He died in 1998 after a short but terrible battle with pancreatic cancer. My mother, to whom he had been married for 54 years, was devastated but eventually bounced back. She is now 86 and in an independent-living apartment—incredibly, totally cognitively intact, but with multiple medical issues, some of which I have previously mentioned in my blogs.

The recent Time Magazine article by Joe Klein, “The Long Goodbye,” (1)got me thinking about the issue of how we as a society approach the impending deaths of loved ones. Klein points out how lucky he and his parents were to get into the Geisinger system, where patient-centric, integrated and holistic care was provided and his parents were cared for, as he would like to be. He states, “Doctors are trained to do whatever they can to save a patient, even an elderly one, and that is an excellent thing. But that Hippocratic impulse has been subtly undermined by the rewards of fee-for-service medicine and by the threat of malpractice suits, which militate in favor of ordering the extra MRI or blood test or dialysis even for a patient who probably has only weeks to live.…” A few days later Austin Considine, writing in The New York Times, noted that Klein was only one of many who have recently written on this topic, with articles in New York magazine and The Atlantic Monthly in the past year articulating the same themes (2). The managing editor of Time, Richard Stengel, notes, “[this is] an issue that’s always on people’s minds…every day there are thousands and thousands of people making these agonizing life-and-death decisions.”

These musings by noted popular writers were brought into focus for me, not because of the frailty of my mother’s medical condition, but by an outstanding article in the recent American Journal of Kidney Disease by Jane Schell and colleagues: Discussions of the Kidney Disease Trajectory by Elderly Patients and Nephrologists: A Qualitative Study (3). The purpose of the article was to better understand with whom nephrologists and elderly patients interact and discuss the future at various stages of kidney disease. The results are fascinating and worth summarizing.

Schell developed a process map of the progress of kidney disease, from diagnosis to disease progression to treatment preparation to dialysis to end of life. She then was able to identify, through questionnaires and interviews, themes for patients and nephrologists at each of these steps. For patients, Schell’s process map indicated diagnosis leads to shock, and then, as treatment preparation begins, patients are quite uncertain about how the disease will progress. As dialysis and further clinical deterioration occur, patients express a lack of readiness for living with dialysis and facing death. For nephrologists, Schell noted there is a real struggle initially to explain how complex kidney disease is, and a real feeling of frustration with the lack of control over the progression of the disease. As dialysis is initiated and clinical deterioration occurs, nephrologists tend to avoid discussions of the future. So what is missing here? We have a failure to communicate! As Schell concludes, “This study shows key areas within nephrologist-patient communication amenable to interventions that address patient understanding and treatment decision making. Effective communication has been shown to enhance patient understanding, shared decision making, and implementation of care plans consistent with patient preferences and goals.… These data show the gaps that exist in how nephrologists and elderly patients discuss and understand the kidney disease course. Interventions that focus on addressing emotion, uncertainty, and understanding may improve patients’ experiences. Effective communication may enhance patient-centered care and promote greater shared decision making.”

It is no coincidence that the recent RPA Clinical Practice Guideline is titled “Shared Decision Making in the Appropriate Initiation of and Withdrawal from Dialysis.” In order to share, one must communicate. Seeing frail, elderly patients in the office quarterly or the dialysis facility only once monthly is insufficient to permit the relationship-building, the establishment of trust, that is essential for true, deep discussions of these personal but critical issues.

Francis Weld Peabody was a distinguished clinician and teacher, educated at Harvard and Johns Hopkins in the early 20th century. His words first published in JAMA nearly a century ago still ring true:

“The good physician knows his patients through and through, and his knowledge is bought dearly. Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine.… One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”

Striving to bring quality to life,

Allen R. Nissenson, MD
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1. Klein J. Time Magazine, June 11, 2012.
2. Considine A. The New York Times, June 13, 2012.
3. Schell J.O., et al. AJKD 59:495, 2012.

My wife is a maniacal exerciser. Three days a week at the gym, weights and cardio; two days a week, Pilates; Saturday, walk on the beach with a girlfriend; Sunday, walk on the beach with me. Although she comes from a family of women with osteoporosis, she has incredible bone density.

Two weeks ago, we were in Santa Barbara visiting our niece, her husband — a postdoc at University of California–Santa Barbara — and their beautiful five-month old daughter. After a wonderful visit, we took off for a relaxing lunch and stroll in Carpenteria, a few miles south of Santa Barbara on the way home to Los Angeles. We were walking around the main drag when my wife turned to point to a cute shop, tripped, and hit the ground. Her foot immediately began to swell, so we got some ice for the one-hour drive home.

Over the weekend, we treated the foot with ice, heat and liberal painkillers, but by Sunday night we knew that we would need to see an orthopedist for an examination and x-rays. That is when it began to get really painful.

On Monday morning, I contacted the chief of orthopedics at a nearby hospital who had his assistant squeeze my wife in to see someone at noon that day. The administrative assistant who made the arrangements couldn’t have been nicer, and we felt like we were on our way to a resolution. We drove to the new state-of-the-art facility. It was a blustery day, and we had been told that we should drive up to valet parking so we could get a wheelchair to take my wife to the appointment. When we pulled up, the valet said, “Sorry, the garage is full.” I insisted that I needed to help my wife to the appointment; after consulting his colleagues, the valet came back with a ticket and took the car.

We walked to the bank of patient elevators, about a block inside the building, rode to the second floor and arrived to find out they had no record of the appointment. I called the administrative assistant who had made the arrangements, and she got that straightened out: “computer malfunction.” Next was the foot x-ray, with the patient having to navigate two large, heavy doors while holding a “patient notification pager” to get from the waiting room to x-ray. We saw a senior orthopedist, who diagnosed a Lisfranc fracture after the examination and review of the films. He thought an MRI should be done to better see the tendons and determine if a cast or surgery would be best. He wrote the order but said we would get a call in a day or two after the authorization was obtained.

By Wednesday, we hadn’t heard from the office and called — we were told they had the request but only one person in the office was authorized to interact with insurance companies, and she was out. Needless to say, after two additional days of pain and essentially no treatment, my wife was outraged. The office said they would see what they could do and would call us back. We called again on Thursday, and they said that the “insurance person” was still out; the one on the phone said it was not her job, but she would see if she could help and would return our call. When we called Friday morning, after not hearing from anyone on Thursday, we were agitated but glad to hear that the MRI had been authorized. We were instructed to call radiology for an appointment.

When we called, radiology said the earliest appointment was for the following Monday. We were incensed — a painful, though admittedly not life-threatening injury, and another several days before the needed test so that the correct treatment could be started. I again called the chief of orthopedics, and the administrative assistant called back in five minutes to say we could get the MRI at noon that day.

We were grateful, and my wife had a friend take her to the test. After it was completed, she asked the technician to please have the radiologist call the orthopedist with the results as soon as they were ready. He stated that the test was not marked “stat” and would be read the following Monday. When my wife went up to the desk to ask the radiology administrative assistant how to get this expedited, the assistant was sitting at the desk, eating lunch, and said, “There is nothing that can be done. It’s not marked stat, and only the ordering doctor can change that.” A final call to the chief of orthopedics, the MRI was read, and it showed not one but two fractures and the possible need for surgery.

No one could make up a story such as this, but it is all too common in our current healthcare system. None of the individuals involved in my wife’s care was hostile, rude or uncaring. They were all working within a system, however, that does not place value on being patient-centric. Like most of our care delivery system, perhaps with “elite” private and academic health centers the poster-children, it is more about “them” than it is about “us” when we are patients. Building beautiful new facilities and having the latest technology has little value when the system forgets why it exists — to provide compassionate, timely, high-quality care for individuals who are in pain, frightened and at the mercy of the system.

By the way, the fact that I was able to “pull strings” to accomplish even what was eventually done is not something of which I am proud. Like any husband, I was willing to do all that I could to make sure my wife was cared for in the best way possible. I am no different from any other husband, wife, son or daughter who wants only the best for their loved one. No one deserves anything less.

We should always remember that as physicians and healthcare workers, we are here to serve patients. As the founder of modern nursing, Florence Nightingale, said more than a century and a half ago: “Apprehension, uncertainty, waiting, expectation, fear of surprise, do a patient more harm than any exertion.”

Apollo 13 returned from moon orbit safely, and I hope we have the wisdom, foresight and ability to work together in teams to rescue our ailing healthcare delivery system.

I look forward to your comments, until next time.

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

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We have to admit — we are coming late to the party! The concept of a culture of safety began outside of healthcare in organizations that self-characterized as “high reliability,” where highly complex and often hazardous activities are a daily reality. Such organizations live and breathe safety from the senior executives to the frontline workers. The Agency for Healthcare Research and Quality (AHRQ) suggests that the following are key features of a successful culture of safety:1

• Acknowledgment of the high-risk nature of an organization’s activities and the determination to achieve consistently safe operations
• A blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment
• Encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems
• Organizational commitment of resources to address safety concerns

There are national efforts ongoing outside of AHRQ to address safety in healthcare, most notably the National Patient Safety Foundation (NPSF).2 This independent, nonprofit organization was established in 1997 and continues to provide programs to assist organizations in focusing on safety in healthcare. In 2006, a survey was conducted, led by the Renal Physicians Association (RPA), to get insights from patients and professionals on the state of patient safety knowledge and programs in ESRD/dialysis. This effort culminated in an ongoing website, Keeping Kidney Patients Safe, which is a fantastic resource in this area.3

Through the survey mentioned above, key areas of focus were identified, including hand hygiene, patient falls, incorrect dialyzer or solution, medication omissions or errors, non-adherence to procedures and venous needle dislodgement. Clearly, these are important issues of patient safety, and there are likely others that need attention as well. Missing from this list, however, are provider safety issues such as needle punctures. With the shrinking workforce in dialysis, keeping our colleagues in the dialysis facility safe is also an important imperative.

So, how do we implement the culture of safety in our facilities? By making a commitment as nephrologists and medical directors to make this a core part of how we function. The American Association of Kidney Patients (AAKP) has tried to get the patients involved in the effort with their national program, 5 Steps to Safer Health Care, described by Dr. Alan Kliger:4

• Speak up if you have questions or concerns
• Keep a list of all of your medications
• Make sure you get the results of any test or procedures
• Talk with your doctor and healthcare team about your options
• Make sure you understand what will happen if you need surgery

We need to make a commitment as we enter 2012: Establishing a culture of safety in our facilities will be a great gift for our patients and our staff, and we will make it happen! To do this successfully will require reassessment of the systems of care we currently have and a willingness to make the necessary changes.

As recently stated by Dr. Paul Batalden (and possibly attributable to W. Edwards Deming and/or Donald Berwick) of Dartmouth Medical School and the Institute for Healthcare Improvement (IHI):

“Every system is perfectly designed to get the results it gets.”

I look forward to your comments, until next time.

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

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References:

1.    http://psnet.ahrq.gov
2.    http://www.npsf.org
3.    http://www.kidneypatientsafety.org
4.    http://www.aakp.org