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. Propensity score matching was used in comparisons of DaVita Rx and control patients with regard to hospitalizations and mortality, and both intention-to-treat and as-treated analyses were performed. The authors concluded, “Receipt of integrated pharmacy services was associated with lower rates of death and hospitalization in hemodialysis patients with concurrent Medicare and Medicaid eligibility.” When looking at the as-treated analysis, considering the time patients were in the program, DaVita Rx patients experienced a 21 percent longer life expectancy, a 7 percent lower rate of hospitalizations and a 14 percent lower number of hospital days. We had previously shown that adherence to prescribed medication regimens was significantly greater in patients using the integrated pharmacy program than in those who were not, suggesting that if patients take their prescribed medications (after doctors have ensured that the medications are appropriate) clinical outcomes are better.

Making integrated pharmacy services available to ESRD patients is not only a way of achieving the Triple Aim of improving the health of the population, delivering patient-centric care and controlling the costs of care—it is an important step in responding to the Centers for Medicare & Medicaid Services plan to include certain oral medications in the ESRD Prospective Payment System (PPS) in 2016. Doing so could be a great gift to patients if providers are able to deliver the service effectively and efficiently and if the payment contribution to the bundle is appropriately determined. Feldman and colleagues recently provided an analysis from the public-policy perspective on the issues around moving Medicare Part D (the “drug benefit”) medications into Medicare Part B (in this case, the ESRD bundle or PPS) (4). They pointed out the many policy and methodological issues that need careful consideration to avoid unintended consequences on patients and dialysis facilities.

These include the following (quoted directly from Feldman et al):

• What definition and metric to use for “utilization”
• What data source to use as the basis to measure historic utilization”
• What year to use as the base year to estimate utilization
• How best to represent estimated utilization as dialysis facility “acquisition cost”
• How to account for dispensing and administrative costs
• How utilization is affected by differences in patient out-of-pocket costs when moving from Part D to Part B

One of the most important issues in calculating an appropriate payment in the bundle is drug utilization. Again, Feldman et al point out the many issues that confound this calculation: “Prescriptions are filled at variable increments ranging up to 90 days. Therefore, accurate estimation of volume per treatment should be based on patients receiving dialysis for periods of 6 months or longer; drug volume needs to be calculated in relation to treatments received by the same patients over the defined time period so that the numerator of drug volume and denominator of treatments are correctly matched—this was not done in CMS’s 2010 analyses; the National Drug Codes for different versions of a single product sold in different doses need to be rolled up together and converted to milligrams; once volume of each drug is calculated on a per treatment basis, it is monetized by applying the most appropriate price proxy. The authors used 2010 and 2011 wholesale acquisition cost for branded drugs and a blended acquisition cost reported by pharmacies that donated data for generic calcium acetates. The monetized volume per treatment is summed across all products to produce the total ingredient valuation per treatment for the mean utilization.” Although this approach to utilization is likely to yield accurate estimates of current utilization, it does not take into account the impact of improved adherence to medications on total medication use and cost, something that may be expected as enhanced pharmacy services are made available to patients. It is of note that the approach to and benefits of integrated pharmacy services provided in the dialysis facility closely mirror those described recently for patients with other complex illnesses (5).

The authors conclude by stating that the complex care of ESRD patients may be improved or worsened by the inclusion of certain oral medication in the bundle in 2016. To achieve its goal of incentivizing better outcomes using the PPS approach, CMS would be wise to approach this issue with the same rigor and intensity as have Feldman and colleagues.

In summary, meds matter to ESRD patients, and the inclusion of selected medications in the PPS in 2016 is an opportunity to further improve the lives of patients with kidney disease. But that improvement will happen only if this part of the PPS is carefully and thoughtfully developed with full input and collaboration from the stakeholders in the kidney care community—including patients, dialysis facilities and physicians.

As Hippocrates said,
“Life is short, and Art long; the crisis fleeting; experience perilous, and decision difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate.”

References:

1. Manley HJA, Canella CAA, Bailie GRA, St. Peter WLA. Medication-Related Problems in Ambulatory Hemodialysis Patients: A Pooled Analysis. Amer J Kidney Dis 2005, 46:669–680.
2. Manley HJ, Garvin CG, Drayer DK et al. Medication Prescribing Patterns in Ambulatory Hemodialysis Patients: Comparisons of the USRDS to a Large Not-for-Profit Dialysis Provider. Nephrol Dial Transplant 2004; 19:1842–1848.
3. Weinhandl ED, Arneson TJ, St. Peter WL. Clinical Outcomes Associated with Receipt of Integrated Pharmacy Services by Hemodialysis Patients: A Quality Improvement Report. Am J Kidney Dis 2013 Apr 15. pii: S0272-6386(13)00571-4. doi: 10.1053/j.ajkd.2013.02.360. (Epub ahead of print.)
4. Feldman RL, Desmarais MP, Muller JS. Orals in the Bundle: A Policy Framework. CJASN ePress 2013 Apr 18. doi: 10.2215/CJN.11621112.
5. Viswanathan M, Golin CE, Jones CD et al. Interventions to Improve Adherence to Self-Administered Medications for Chronic Diseases in the United States—A Systematic Review. Ann Intern Med 2012; 157:785–795.

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.

We need to acknowledge that educating the U.S. public about kidney disease may be an insurmountable task. At the same time, 43 percent of our patients have never seen a nephrologist prior to crashing into dialysis. We know how deeply that lack of knowledge, preparation and care impacts patients’ lives and quality of life. Doing nothing to educate patients about kidney disease is not an option either.

Maybe the solution lies in letting go of our desire for everyone to know about kidney disease, and embracing the task of educating two specific audiences: those at greatest risk for CKD and those with the greatest ability to help diagnose CKD.

The good news for patients at risk is that there are plenty of great resources available to provide education about CKD. The National Kidney Foundation has just launched a public-awareness campaign, and DaVita has created a national public-service announcement (featuring NBA all-star Alonzo Mourning and celebrity comedian George Lopez) to stress the importance of knowing risk factors, getting tested and staying off dialysis (www.davita.com/kidneyaware). The key is to find these patients and reach them directly.

A good start would be to establish much stronger relationships between the kidney community and groups representing patients with diabetes and hypertension. Another valuable step would be to build relationships with interest groups for African Americans, Hispanics and other people of color who are at greater-than-average risk.

Another important opportunity for reaching patients before crisis strikes is found in primary-care providers. For anyone who questions whether further education for primary-care providers can make a meaningful difference in early diagnosis, one recent study, Awareness, Detection and Drug Therapy in Type 2 Diabetes Mellitus and Chronic Kidney Disease (ADD-CKD), conducted by the National Kidney Foundation, is informative. The multisite, cross-sectional study released last year found that kidney disease is still significantly under diagnosed among those with diabetes. Of 9,307 diabetes patients studied, 5,000 had chronic kidney disease (based on proteinuria and eGFR). Yet prior to the study only 607 had been accurately identified by their physicians as having kidney disease.

We need to figure out how to make CKD testing a given for PCPs. Every patient history should include questions about any family history of kidney disease. Annual tests should be an automatic assumption for patients with diabetes or hypertension; for patients with a family history of kidney disease; and for patients who are of African, Hispanic, Native Alaskan or Pacific Islander descent.

What if each of us sent a short, simple email to every PCP in our personal networks, sharing major risk factors that merit screening, current eGFR standards for diagnosis and suggested next steps for patients who have been diagnosed with CKD (including DaVita’s excellent Kidney Smart education program—www.kidneysmart.org)?

Kidney disease awareness is a complex problem, but there’s no better time than National Kidney Month to consider new approaches. I hope this is something we can talk about at the National Kidney Foundation Spring Clinical Meetings in April; busy as we are, we can do more to educate those with CKD, as well as our fellow physicians.

Share with us your creative ways for educating others about kidney disease and understanding major risk factors that merit screening. Tweet your ideas with #kidneyaware or comment on this page.

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

Follow me on Twitter @DrNissenson

A recent editorial in the New York Times described a move by the New York City public hospital system to “pay doctors based on how well they perform.” (1) Under this program, the more than 3,000 salaried doctors at the NYU School of Medicine, the Mount Sinai School of Medicine and the Physician Affiliate Group of New York will receive no cost-of-living increases for the next three years, but there will be annual bonuses tied to meeting quality-performance goals. In the same issue of the Times there is an important critique of the pay-for-performance (P4P) approach, describing what many policy experts have said for years: “If only it worked.” (2) Op-ed columnist Bill Keller points out that the real driver of costs in our healthcare system is not overutilization of services, but rather the high unit cost of each service. Others may debate this premise, but the reality is likely a bit of both—more units and higher cost for each. As Bill Clinton said during the 2012 Democratic National Convention, “it’s math, folks,” and P4P is unlikely to change these factors significantly.

Rather than speculate on whether P4P is effective in changing physician behavior, improving quality and controlling costs, what can we learn from studies? Houle and colleagues from Canada recently published an exhaustive systematic review of this topic. (3) Unfortunately, their work showed that the number of rigorous, evaluable programs was quite small, making it difficult to draw firm conclusions on the effectiveness of P4P. Others have commented that “evaluation of pay for performance initiatives has not kept pace with the rush to implement them….” (4) Houle et al conclude, “Although P4P seems to be useful in business settings and may serve as a means to signal which elements of care are valued within a participating health care organization, the current evidence for P4P targeting individual practitioners is insufficient to recommend wholesale adoption in health care systems at this time.”

That brings us back to the beginning: how can nephrologists continue to be motivated to drive higher quality for kidney patients while controlling the overall costs of care? Certainly P4P, if appropriately constructed (meaningful, actionable metrics; significant payments for quality; full transparency and other requirements) can play a role, but experience suggests that such programs are generally not designed to optimize impact. Johns Hopkins professor Peter Pronovost, the guru behind eliminating catheter-associated bloodstream infections (CABSI), suggests that driving better quality should not require “bribing” doctors, but rather playing to doctors’ professionalism. Is this just pie-in-the-sky thinking?

We have a case study in nephrology that makes Pronovost’s point. The Renal Physicians Association put together a task force several years ago to look at CKD care. (5)  In collaboration with investigators at Duke University, data from nearly 2,000 CKD patients was analyzed through chart reviews to see how well nephrologists and non-nephrologists adhered to available clinical practice guidelines in this area. Although nephrologists performed better than non-nephrologists, neither group’s performance was stellar. Participating nephrologists were provided the results of the study, and repeat chart reviews were conducted six months later. Results improved dramatically. (6) The only incentive was seeing the data and the need to improve! As we all look at schemes to implement P4P programs, we need to have a healthy skepticism about their value in driving outcomes and always remember that the real driver is the Hippocratic Oath we all took!

Let’s commit to keeping medicine a noble profession. As William Osler said,

“The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with potions and powders, but with the exercise of an influence of the strong upon the weak, of the righteous upon the wicked, of the wise upon the foolish.”

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

Follow me on Twitter @DrNissenson

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⁽¹⁾  www.nytimes.com/2013/01/28/opinion/paying-doctors-for-performance.html?_r=0

(2) http://www.nytimes.com/2013/01/28/opinion/keller-carrots-for-doctors.html?pagewanted=all

(3) Houle SKD et al. Does Performance-Based Remuneration for Individual Health Care Practitioners Affect Patient Care? Ann Intern Med 157:889–899, 2012.

⁽⁴⁾  Mannion R, Davies HT. Payment for Performance in Health Care. BMJ 336:337:a867, 2008.

⁽⁵⁾  Patwardhan MB et al. Clin J Am Soc Nephrol 2:277–283, 2007.

(6) Haley WE. Personal communication, 2012.

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.

Key success factors include a deep commitment to the team approach, a strong culture of excellence and responsible stewardship of resources, comparative-effectiveness research and evaluation and a staff model of physician engagement. The latter includes one-year renewable contracts with employed physicians, the use of structured annual performance reviews and financial incentives based on quality outcomes. Michael Porter, the Harvard Business School guru of healthcare organizational structure, has said that the Cleveland Clinic represents “a model of where we need to go.”

How much of the success of the Cleveland Clinic and other similar organizations depends on the staff model—something that has barely touched nephrology but has been exploding on the scene in a big way in other primary-care fields and subspecialties? Only 38% of physicians in the United States were in independent practice at the end of 2012, and this number is expected to shrink to 30% or so by the end of 2013. Many would say that employed physicians, given the right incentives based on quality outcomes and a fully integrated care-delivery system, are the most able to deliver on the promise of better outcomes at lower cost, at least for the chronically ill complex patient.

Whether or not you agree with this premise, it is important to keep in mind some key principles if you do choose to become employed by a care-delivery system or hospital. These principles are articulated by the AMA in a recently published position paper: AMA Principles for Physician Employment (http://www.ama-assn.org/resources/doc/hod/ama-principles-for-physician-employment.pdf).

A few of the key points are worth reprinting here:

(a) A physician’s paramount responsibility is to his or her patients.… Given that an employed physician occupies a position of significant trust, he or she owes a duty of loyalty to his or her employer. This divided loyalty can create conflicts of interest…which employed physicians should strive to recognize and address.

(b) Employed physicians should be free to exercise their personal and professional judgment in voting, speaking, and advocating on any matter regarding patient care interests.…

(c) In any situation where the economic or other interests of the employer are in conflict with patient welfare, patient welfare must take priority.

(d) Physicians should always make treatment and referral decisions based on the best interests of their patients.…

(e) Assuming a title or position that may remove a physician from direct patient-physician relationships—such as medical director…—does not override professional ethical obligations.… Physicians who hold administrative leadership positions should use whatever administrative and governance mechanisms exist within the organization to foster policies that enhance the quality of patient care and the patient care experience.…

Good advice (and there is lots more) for all of us.

As Plato asked more than 2,000 years ago,

“Is it not…true that no physician, insofar as he is a physician, considers or enjoins what is for the physician’s interest, but that all seek the good of their patients? For we have agreed that a physician strictly so called is a ruler of bodies, and not a maker of money, have we not?”

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

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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?”

I lived in Los Angeles during these difficult times and I was reminded of them when I read a recent article in The New York Times: “A Hospital War Reflects a Bind for Doctors in the U.S.” (http://www.nytimes.com/2012/12/01/business/a-hospital-war -reflects-a-tightening-bind-for-doctors-nationwide.html). The story is about the battle between two dominant hospitals in Boise, Idaho, that are in deep competition and together employ nearly half of the doctors in that part of the state. Physicians are bitterly complaining about the ongoing competitiveness, citing disruption of referral patterns, care driven by system financial-performance metrics and loss of autonomy for doctors. The real losers are the patients, whose access to choice in care has diminished and whose costs of care have risen. “First do no harm” is nowhere to be seen.

Although the hospitals involved deny any unintended consequences of the consolidated environment and acquisition of physician practices, the article drew a number of concerned letters in a subsequent issue of the Times (http://www.nytimes.com/2012/12/10/opinion/when-hospitals-buy -doctor-practices.html?_r=0). The president of the American Hospital Association weighed in, as did the president of the American Medical Association and several doctors and patients. The comments made one thing clear: getting along without losing sight of the ultimate goal—greater value in healthcare, better quality at a lower cost—is extremely difficult. Former senator Bill Frist, a heart-transplant surgeon, clearly articulated the direction in which I believe we need to go: “A more activist professionalism among doctors must openly counter the unspoken and unacceptable incentives that too often define doctor-hospital ‘productivity’ more in terms of financial gain than patient outcome.… In health care today, we are going through a tumultuous transition, with the new federal health reform law, escalating cost of health care, large mandatory cuts for doctors occurring in January, and certain reduction in Medicare financing in the fiscal-cliff negotiations. To get it right, all incentives…must realign solely around value to the patient.”

As general integrated care–management programs get formed, three entities are trying to do the organizing: hospitals, insurance companies and physician groups. The misalignment of incentives for hospitals is clear—when integrated care management has as a primary goal keeping patients healthy (that is, out of the hospital), this creates significant problems for hospitals. Insurers are better positioned since they are familiar with taking risks, but they often have to focus on utilization management to contain costs.

Physicians should be in the driver’s seat in this emerging world. Physicians can evaluate the best current medical evidence and do the appropriate testing and treating based on it. Whether you call this the application of comparative effectiveness knowledge or common sense, it is doctors who are best positioned to drive better clinical quality while controlling costs. Unfortunately, however, our track record of delivering on such promises has not been good except in a small number of physician groups. HealthCare Partners® is one such group, which is why we are so excited about DaVita HealthCare PartnersSM. The HealthCare Partners credo is that when you do what is best for the patient, you will be doing what is best for the organization.

So that brings us back to the beginning. In order for there to be truly integrated care, we all need to get along. That is the only way to achieve the triple aim articulated by Donald M. Berwick, MD, former CMS chief: better outcomes for the population; better health for the individual; lower costs to the system. Doctors, hospitals, payers and patients need to have aligned incentives and to be committed to holistic, patient-centric care. If we can do this, we can transform healthcare in America.

As Atul Gawande, the guru of the checklist in medicine said,

“[In medicine,] we have trained, hired and rewarded people to be cowboys, but it’s pit crews that we need.… Having great components is not enough, and yet we’ve been obsessed in medicine with components. We want the best drugs, the best technologies, the best specialists, but we don’t think too much about how it all comes together.”

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

Follow me on twitter @DrNissenson

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It seems that everywhere one looks in the healthcare media these days, there are stories about the competitive advantages of physicians using social media. For example, American Medical News recently published a very informative article entitled “Four Ways Social Media Can Improve Your Medical Practice,” which illustrates the ways in which physicians using social media as a listening tool can discover needed services, improve customer service, gather feedback on medications and compare and improve quality.

I don’t disagree that social media offers physicians a valuable listening tool that may well provide some competitive advantage. But I’m much more interested in the collaborative advantage social media offers as a community-building tool.

That’s why I agreed to serve as editor in chief of NephLink (www.NephLink.com), a new social-media community for physicians engaged in kidney care. NephLink will be a primary resource for nephrologists, but all physicians treating patients with kidney disease are welcome on the site. Physicians will be able to use NephLink to connect with each other, to access research and news and to consult on cases.

The simple truth is that as nephrologists we don’t talk with each other nearly as much as we should. We have conferences like ASN and NKF, where we get the chance to hear the latest research and consult with each other, but two or three times a year isn’t enough to overcome the artificial barriers between us—barriers we ought to work vigorously to tear down.

Why can’t DaVita physicians and Fresenius physicians and DCI physicians and  other physicians all learn from each other? Why shouldn’t a young doctor launching her practice have the chance to consult with those who are more experienced—or to share a new insight with them? How are physicians in rural areas or small towns supposed to access the nephrology community outside of national conferences? NephLink, while not a panacea, offers a place where these kinds of conversational obstacles can be removed.

Of course I understand seeking a competitive advantage, but much more than that, I want the collaborative advantage of consulting with my colleagues about difficult cases. I want the collaborative advantage of working with my peers to analyze policy changes that impact kidney patients’ lives and quality of life. I want the collaborative advantage of an equal conversational playing field, where no one has to be nervous about asking tough questions regarding why we do what we do and who’s truly responsible for clinical outcomes and quality of life.  And where we can also listen to each other and engage in adult conversations.

I want to be part of creating that advantage for all of us because the rising tide of collaboration has the potential to lift all of our patients’ boats, helping us become better caregivers, improving safety and quality of care and ultimately saving lives. That’s why I agreed to help lead NephLink; that’s why I think NephLink is an important opportunity for us all.  This is not a DaVita thing, it is a kidney care community thing.

If you’re interested in learning more about NephLink, visit www.NephLink.com. Any licensed physician can register at no cost. A brief online tour of NephLink is available at on YouTube.

We should all listen to the advice of Charles Darwin who said:

“It is the long history of humankind (and animal kind, too) those who learned to collaborate and improvise most effectively have prevailed.”

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

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DaVita is entering the world of international dialysis in a big way. We are partnering with doctors in Singapore, India, China, Malaysia, Saudi Arabia, Germany and other countries. As we embark on this exciting adventure, we again are faced with the nagging perception that dialysis outcomes in the United States are worse than those in other parts of the world. Two recent articles provide fascinating perspectives on this important issue.

Cheng et al. from Beijing, China, examined mortality rates in prevalent hemodialysis patients in Beijing and compared these with data from USRDS. (1) The average mortality rate in Chinese patients had been reported at about 10% during the study years (2007–2010), nearly half that reported for U.S. patients during the same time period. The authors then examined many of the purported factors that might confound and/or explain this comparison. There were clear demographic differences in the populations; in the Chinese group there was a preponderance of males, only 32% of patients were over 65 years old and only 18% had diabetes as a cause of ESRD. Of interest was the fact that 49% of deaths were due to vascular disease, including CVD and stroke. After adjustment for the differences in demographics, including race, Beijing patients had a relative risk of death compared to white U.S. patients of 0.16, 0.26 and 0.42 for 2007, 2008 and 2009, respectively, and similar survival advantage compared to Asian U.S. patients. Of note is the fact that the Beijing patients’ mortality increased 61% from 2007 to 2010, while U.S. patients had a decrease in mortality of nearly 14% between 2004 and 2009 (dates for which data is presented), suggesting that the decreasing gap in mortality rates is primarily related to a worsening rate in Beijing, not to improvements in survival rates in the United States. Despite the closing of the gap, survival in Beijing still exceeds that in the United States. The authors conclude that practice patterns rather than patient differences explain the findings; and in particular the time nephrologists spend with their patients is impactful. In Beijing physicians are present during all treatments. Another factor that may also be important is the significantly lower rate of catheter use in Beijing

The idea that practice patterns rather than management of anemia, adequacy or other aspects of care drive differences in outcomes is not a new one, but two recent studies examine this question in much greater detail (2,3). Slinin and colleagues evaluated the impact of provider-patient visit frequency on hospitalizations and mortality in dialysis patients. Greater frequency of provider visits was associated with a significant reduction of hospitalizations, although there was no association with mortality.

Kramer and colleagues from Amsterdam examined macroeconomic indicators in various countries in an attempt to explain mortality differences. The indicators included GDP per capita; healthcare expenditures as a percentage of GDP; private for-profit share of hemodialysis (HD) facilities; HD-facility reimbursement as proportion of GDP; prevalent dialysis patients per nephrologist; % of diabetes as a cause of renal disease; age- and sex-related mortality risk of the incident dialysis population; and confounders including human development index, responsiveness index, public share of healthcare expenditure and general population-health indicators (including cardiovascular mortality and life expectancy at age 60). Finally, HD-facility reimbursement method, prevalent dialysis patients per center, and incident-patient age and gender were included in the analysis. The key findings were that a higher GDP per capita and a higher healthcare expenditure as a percentage of GDP were associated with a higher two-year mortality rate on dialysis. Perhaps “richer” countries have a more liberal acceptance policy for putting patients on dialysis, as the authors suggest. In addition, a higher intrinsic mortality risk of the dialysis population—based on the mortality of the general population and age and sex standardization of the incident patient population in a country—as shown by others (4,5)—is key to the differential survival rates.

So what are the lessons for U.S. nephrologists and for DaVita as it embarks on its international journey? It seems clear that in the United States, there is no substitute for nephrologists spending time with dialysis patients. The dramatic trend—driven by current reimbursement and increasing time demands—toward monthly nephrologist visits, with additional visits made by other caregivers, arguably is contributing to the problem. While mortality has slowly, steadily improved, none of us can be happy with the current high mortality rate. Recommitting to engaging with our patients is one step that may help. Internationally for DaVita, we must approach our partners with openness and a willingness to learn from them. What are their clinical goals and metrics? How do they interact with their patients and focus on the key areas that drive better outcomes? What do they think are the reasons they have such excellent outcomes? And for those parts of the world where outcomes are not so good or even being measured, two of the great gifts we can bring to nephrologists and patients are rigor and a process for defining the important outcomes, measuring performance and focusing on what is important to patients everywhere—to lead as long and as satisfying a life as possible.

We should all remember as we ponder how we care for our patients in the United States or work with our partners in other parts of the world that often it is they and not we who have many of the answers. As Confucius said,

“He who speaks without modesty will find it difficult to make his words good.”

At the end of the day, nephrologists everywhere need to share their knowledge and experiences, and consider the words of Buddha, as well:

“You should respect each other and refrain from disputes; you should not, like water and oil, repel each other, but should, like milk and water, mingle together.”

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

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1. Cheng X et al. Mortality Rates among Prevalent Hemodialysis Patients in Beijing: A Comparison with USRDS Data. Nephrol Dial Transplant 0:1–7, 2012.
2. Kramer A et al. Exploring the Association between Macroeconomic Indicators and Dialysis Mortality. Clin J Am Soc Nephrol 7:1–9, 2012.
3. Slinin Y et al. Association of Provider-Patient Visit Frequency and Patient Outcomes on Hemodialysis. J Am Soc Nephrol 23:1560–1567, 2012.
4. Van Dijk PC et al. Effect of General Population Mortality on the North-South Mortality Gradient in Patients on Replacement Therapy in Europe. Kidney Int 71:53–59, 2007.
5. Yoshino M et al. International Differences in Dialysis Mortality Reflect Background General Population Atherosclerotic Cardiovascular Mortality. J Am Soc Nephrol 17:3510–3519, 2006.

I am becoming more optimistic as I continue to understand and refine the programs of VillageHealth, the DaVita integrated care–management organization, and delve into the incredible success of HealthCare Partners, DaVita’s new partner. This optimism is driven by the belief that physician-led, physician-driven, patient-centric care can not only be accomplished, but such an approach optimizes clinical outcomes while responsibly controlling costs.

A recent set of papers in The New England Journal of Medicine helped fuel this optimism, as well, and begin to outline a “path forward” to make this happen (1,2). Thomas H. Lee, internist, cardiologist and health-policy guru, described what is needed for providers to drive and embrace clinical-care redesign, including key aspects of strategy, tactics and operations. While the concepts seem intuitive and simple, implementing them successfully is challenging for physicians working independently or in groups or organizations.

First, there must be an explicit strategy clearly articulating what the physician or organization is trying to accomplish, developed with a focus on what matters most to patients. Implicit in this is an absolute commitment to not only defining important outcomes, but also to measuring them in a transparent and reproducible way. It is important that important outcomes are measured even if the evidence behind them is imperfect. The goal is not to conduct an academic exercise, but to assist physicians in decreasing variations in care and outcomes and to enable application of best knowledge and practice at the time. When he speaks of “outcomes that matter,” Lee emphasizes that “hard outcomes (e.g., mortality) are…important, and doing significantly worse than expected…represents a major crisis. But…many such outcomes are largely determined by disease severity, it may be difficult or impossible for organizations to improve beyond the expected range.” This suggests that not only relevant outcomes, but also new methods of collecting, analyzing and reporting such data may be needed to fully capture the multidimensional aspects of quality.

Second, specific tactics must be developed to enable deployment of the strategic approaches described. Care-design teams must get into the trenches of patient care. Care processes need to be mapped in detail and then care re-engineered to be more efficient, outcomes-driven, and patient-centric. There must be continual feedback to make sure care teams understand the care processes and receive data in real time to reinforce the steps needed to optimize outcomes. This is a process that needs to be done at the local level, where care is delivered. While templates for best practices for care processes are a good starting point, all healthcare is local and customization is needed to take into account local patient characteristics, physician practice patterns and community resource availability.

Finally, none of this can happen without a strong commitment to teams—multi-disciplinary teams that not only provide the hands-on care, but also work together to develop the systems of care described above. The purpose in the end, as Lee states, is to “improve the value of care.”

Of course, we know that we operate largely in the world of a public payer, Medicare. How can we apply these principles to the Medicare-served, chronically ill, ESRD population? The second recent paper, coauthored by Patrick Conway, the CMO of CMS, suggests that our primary public payer is trying to move in the direction Dr. Lee suggests. CMS has now embraced the “triple aim” of the American healthcare system: better outcomes for individuals, better outcomes for populations, and lower overall costs. One of the tools being used is a movement to value-based purchasing—in ESRD, the Quality Incentive Program. Articulated in this paper are the five key principles that are important in driving value: 1. The end goal must be defined; 2. Provider incentives must be aligned; 3. The right measures must be developed and implemented rapidly; 4. Improvement as well as absolute performance must be supported; 5. The clinical community and patients must be actively involved in the process. Not very different from the overall redesign needs described by Lee.

At the end of the day change is always difficult, and in healthcare this has proven to be particularly the case. VanLare and Conway state, “Shifting to a culture of shared accountability for patient and community outcomes and costs will be a journey…”—one that Lee concurs will not be short or easy: “The approach to redesigning care requires the humility to concede that we are not as good as we can or should be, that we can learn from others, and that we need tools…to improve.…” Certainly in nephrology we cannot be satisfied with the outcomes of our patients with CKD/ESRD.

As integrated-care management, whether through ACOs or other vehicles, rapidly becomes an important approach to the care of the chronically ill, nephrologists have an opportunity to drive the teams that can make the “triple aim” a reality. This is being done today by HealthCare Partners as well as VillageHealth.

Business magnate and philanthropist Warren Buffett could have been describing healthcare in America, and certainly the care of the complex, chronically ill when he said,

“In a chronically leaking boat, energy devoted to changing vessels is more productive than energy devoted to patching leaks.”

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

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1. Lee TH. Care Redesign—A Path Forward for Providers. N Engl J Med 367:466, 2012.
2. 2. VanLare JM, Conway PH. Value-Based Purchasing—National Programs to Move from Volume to Value. N Engl J Med 367:292, 2012.

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.