Editor’s note: Fresenius Medical Care chief medical officer Frank Maddux, MD, recently authored a paper entitled, “Doing more than caring about quality” (Seminars in Dialysis March/April 2016). In an interview with NN&I, we ask him about points made in the paper and how he believes dialysis patient care can improve.

This article is part of NN&I’s 22nd annual dialysis provider rankingFresenius Medical Care North America is the largest provider in the United States.

NN&I: You mention “individualized patient care is forthcoming…” Is that possible for a company that provides dialysis treatment for over 180,000 patients?

Frank Maddux, MD: There are ways to use technologies to work toward a more personalized prescription. I think we would still have standardized approaches to the treatment, but we would have opportunities to address the individual’s needs at chairside and adjust the prescription. It is a combination of technology and process, and we can individualize care even in large organizations.

NN&I: In the opening paragraphs of the Seminars article, you say “Advancing the care of patients with severe renal failure has been both a success and a failure” and we need a “roadmap to guide a fundamentally evolved approach.” What can the provider community do better?

Maddux: We have removed renal disease as a cause of death for thousands of individuals. But now, particularly with more interest in value-based care, there is an opportunity to expand beyond just the treatment. As a community, we need to be always pushing the boundaries to make a treatment better, safer. I never think that we are done. There is a lot of room for continued improvement.

NN&I: You wrote, “Such actions should target improvement in outcomes…such as reduced annualized mortality rates by 10%…hospitalization rates, and improve mental and physician patient reported health outcomes.” What is your view on how a patient’s mental health impacts outcomes?

Maddux: When you think of overall patient outcomes, they can be influenced by many things beyond just the physiology of the illness. That includes a patient’s mental state, their decision-making when they sit in front of you, how they participate in family issues and their communities. Mental and physical component scores are both important when making patient care decisions.

NN&I: Likewise, you wrote, “Changing the nature of our approach to one of continuous assistance, monitoring and support of patient decision making is where a fundamental shift must occur…” Do you think patients want more engagement at home with their caregivers (via telehealth, etc.)? Is patient-to-caregiver still the best opportunity?

Maddux: For most of our patients, it’s not about diagnosing the disease. It is about preventing the known crisis events from occurring. When you think about the fact that you only see them about 10% of their time, you want to engage them and activate them. Your question to them is, “What are you trying to accomplish with this chronic illness that you have––what are your goals––and what are you willing to do to meet those goals?” We want to help them prevent these non-crisis issues: avoid missed treatments, avoid overeating (leading to too much potassium), etc. We want to identify those things that drive good health decisions.

Regarding influence on patient care, I believe that, at the end of the day, the thing that makes the greatest impact on how a person deals with health issues is another person. It could be a member of a health care delivery team; it could be a friend or family member. And technology can play a role in it.

NN&I: There is an uneasiness of discussing palliative and supportive care. How do you come up with a happy medium that physicians can support?

Maddux: There isn’t a simple solution. It is important to sit down with your patients and recognize what they are after––what are their goals, what we are targeting for their treatment. Modality options can be tied to these patient goals.

Likewise, we need to recognize that we have a culturally diverse group of providers in nephrology, with many different backgrounds. We need to be sensitive to that and their beliefs. 

NN&I: Nephrology as a subspecialty is hurting for enthusiastic renal fellows. Tell us more about your vision of a cardio-renal nephrologist.

Maddux: We know the nephrology fellowships have struggled in the last few years. So many outcomes in nephrology are driven by cardiovascular disease. But we don’t really train nephrology fellows in chronic disease categories, like CVD. There is an opportunity to develop a new approach for the nephrologist that includes the cardio experience. It could really rebuild our specialty and create a renaissance in nephrology.