Teamwork will not only improve patient outcomes but also reduce healthcare costs associated with CKD
Missouri spends millions on diabetes-related medical care each year, and much of that goes toward treating complications of the disease rather than prevention.
The state has struggled with both the human and financial costs of the disease, as well as with promoting the best practices for its treatment. For example, Missouri has room for improvement when it comes to promoting the use of arteriovenous fistulas – called the “gold standard” for access to the cardiovascular system -- as a first choice for hemodialysis when a patient reaches Stage 5 of Chronic Kidney Disease (CKD).
An intelligent approach to this challenge lies in cooperation between primary-care physicians (PCPs) and nephrologists. PCPs can work with patients to prepare for the later stages of kidney disease, educating them about the benefits of fistulas.
“Optimal care of the patient with Chronic Kidney Disease (CKD) requires early referral and a strong partnership between the nephrologist and the primary care physician (PCP) – teamwork,” says Gary G. Singer, MD, nephrologist and President of Midwest Nephrology Associates in St. Louis, MO.
Working with nephrologists, PCPs have a great opportunity to increase patient education. CKD patients who know the course of their disease can begin treatment to slow the progression or address risk factors. The PCP has the benefit of a long-term patient relationship to guide the patient in understanding their disease and the importance of tracking their estimated glomerular filtration rate (eGFR). This introduction can allow the patient to realize that Stage 4 means preparing for Stage 5 and preparing for Stage 5 means vessel mapping and fistula placement if their treatment choice is hemodialysis.
Ideally, primary care physicians will identify CKD early through annual eGFR testing and annual urine microalbumin screening for high-risk patients including those with diabetes or hypertension. They will start treatment in Stages 1 through 3, slowing the progression of CKD and potentially preventing the need for hemodialysis. PCPs can also begin renal replacement therapy counseling as appropriate, allowing nephrologists to focus on patients needing specialized care. Nephrology consultation should begin in Stage 3 (eGFR below 60 m/min.), but primary care can continue to manage care. Stage 4 (eGFR below 30 m/min.) will trigger vessel mapping and fistula placement to ensure maturation prior to hemodialysis.
More effective treatment of CKD may also address the high cost of healthcare today. In 2006, nearly $1 in every $4 spent by Medicare went toward patients with CKD. Vascular access complications account for 16 to 25% of all hemodialysis patient admissions. Improvement has been made. Since the 2002 publication of the Kidney Disease Outcomes Quality Initiative (KDOQI) and subsequent campaigns such as Fistula First, fistula placement has become the nationally predominant form of vascular access.
Again, AV fistulas are the “gold standard” for vascular access. They reduce serious infections, mortality and other complications normally associated with grafts and central venous catheters. They cost less to maintain and generally require less rework and cause fewer complications that require hospitalization. 2 Currently, they’re still used less than half of the time in Missouri.
An adequately prepared dialysis patient is far more likely to undergo fistula placement. This is not only logical, but it works in practice. In a 2004 study, one clinic saw fistula placement increase from 24% (respectable at the time) to an outstanding 83% after simply implementing a pathway to educate and coordinate pre-dialysis care for CKD patients.2
There are a number of challenges for such efforts. For example, CKD is under-diagnosed. An estimated 12 million Americans have moderate to severe CKD (Stage 3 to 5). 3 According to the 2004 Renal Detection and Referral Study, 42.4% of patients still lacked diagnosis upon reaching Stage 4 CKD, 4 the stage when fistula placement is generally most appropriate to allow six months for maturation.5
So when to refer a patient to a nephrologist, and perhaps suggest it’s time for a fistula? Brent Miller, MD, Washington University School of Medicine Associate Professor of Medicine, Division of Nephrology, notes some patient triggers for nephrology referral:
- Acute increase in serum creatinine without explanation
- Suspicion of glomerulonephritis
- Poor blood pressure control despite diuretic and ACE/ARB therapy
- Inability to manage edema
- Progressive increase in creatinine over time
The current situation calls for such vigilance. Nearly 53% of Missourians on hemodialysis are not using fistulas, exposing them to unnecessary risks. In 2008, less than one in three Medicare patients had a fistula in place or maturing at the time of their first hemodialysis treatment. Nephrology and primary care must work together to ensure appropriate care and keep kidney failure from being a surprise occurrence.
Comprehensive guidelines on kidney care, including the CKD staging guidelines are available online at www.kdoqi.org. Primaris, Missouri’s Medicare Quality Improvement Organization, is currently one of ten states participating in a CMS pilot project to slow the progression of CKD. Physician and patient education resources are available at
www.primaris.org/CKD.
References:
“2008 USRDS Annual Data Report.” U.S. Renal Data System. http://www.usrds.org/2008/view/ckd_05_costs_of_ckd.asp. Accessed Aug. 6, 2009.
Fistula First Breakthrough Initiative. www.fistulafirst.org. Accessed Aug. 7, 2009.
Centers for Disease Control and Prevention. “Prevalence of chronic kidney disease and associated risk factors-United States, 1999-2004.” MMWR Morb Mortal Wkly Rep 2007.
Singh A, Oppong-Manu P, Mody S, et al. “The Renal Detection and Referral Study (RADAR Study): Applying eGFR Measurement…” Renal Week 2005. Nov. 8-13, 2005.
National Kidney Foundation. KDOQI Guidelines. 2006. www.kdoqi.org. Accessed Aug. 7, 2009.
Physician teamwork can boost Gold Standard in Missouri 