Abstract

Chronic hemodialysis in Seattle developed with a highly patient-centric approach, providing patients the option of dialyzing in neighborhood units under the administration of a non-profit organization, the Northwest Kidney Center (NKC). This study examined the effects of a requirement in the 2009 Conditions for Coverage that in-center hemodialysis patients be visited quarterly during their treatment session. A retrospective analysis of quality outcome indicators for patients managed at the University of Washington Medical Center and dialyzing at NKC in 2008 and 2010 found that dialysis adequacy (eKt/V), phosphorus, albumin, and hemoglobin were not improved by quarterly dialysis visits. Instead, dialysis unit visits adversely impacted patient-nephrologist relationships and diverted nephrologists from other patient care activities.

Background

The hemodialysis program in the greater Seattle area developed by establishing a local non-profit dialysis organization, the Northwest Kidney Center (NKC). Using a patient centric approach, NKC created dialysis units throughout the region so patients could dialyze close to home or work. NKC now has nearly 20 neighborhood hemodialysis units within a 25-mile radius unified by a single electronic record and administrative staff. Patients are able to choose the unit that best fits their schedule and may select any nephrologist in the area since all have privileges at NKC.

Although highly patient centered, the NKC model presented the challenge of having to monitor patients spread throughout many dialysis units. Our solution, implemented in 1995, was a population-based management system for all hemodialysis patients called the Caremap.

The one page Caremap, roughly equivalent to today’s Centers for Medicare & Medicaid Services’ designated comprehensive assessment, was created as a flow sheet of dialysis, laboratory and clinical parameters. Off-target values were highlighted and experienced senior nephrology certified nurses were placed in the position of reviewing Caremap data as soon as electronically available. When patients did not achieve a goal, the nurses inquired about problems, repeated labs within a set of guidelines, arranged for dietitian or pharmacist appointments, and notified nephrologists of concerning issues. The Caremap system improved quality outcomes of dialysis adequacy, anemia, access patency, and albumin while reducing the number and cost of emergency department (ED) visits, admissions, and length of stay.4It also preserved the patient centric approach of NKC where patients could dialyze at a center near their life activities and see the nephrologist of their choice in an office setting. Patients generally met with their nephrologist and nurse monthly in clinic. However, even if visits were missed the continual review of the Caremap and the frequent communications with patients kept them working toward Caremap goals. Physician visits to dialysis units were made as needed, that is, when we were unable to modify procedures without examining the patient while dialyzing. These visits were rare; usually any complications would be assessed during dialysis at the hospital.

Change in physician visits

In 2009, CMS updated coverage conditions for the end-stage renal disease program. Part of that update now required nephrologists to visit patients during outpatient dialysis sessions at least quarterly in order for dialysis treatments to be reimbursed.

This created problems for both nephrologists and patients in the NKC system. Patients in our practice were scattered throughout numerous NKC dialysis units, which meant that each of these dialysis units had to be visited on a quarterly basis at a time when a particular patient was receiving treatment. For example, if one unit serviced five of our patients, but each patient was dialyzing on a different schedule, then five different trips were required to satisfy the CMS requirements and accommodate the patients. If the dialysis center happened to be located far from our site of practice, a nephrologist could drive 50 miles round trip to see one patient. In addition, for patients who still required care in a clinic or hospital setting (common for our tertiary university practice), the dialysis visitation requirement could not replace a visit to the practice site.

Trying to maintain continuity of care with established patients and comply with CMS exhausted the resources of the practice. Nephrologists spent more time driving and less time seeing patients, resulting in a loss of revenue and a backlog of non-dialysis patients needing to be seen in clinic.

Reorganize physician visits

Strategies to comply with the CMS dialysis visit requirement and better utilize nephrologist time included 1) asking patients dialyzing at one center to dialyze on the same shift to accommodate nephrologists’ rounding; 2) limiting the units where patients could dialyze if they wanted to keep their preferred nephrologist; 3) swapping patients between nephrologists where one nephrologist assumed care for all patients dialyzed at a particular unit.

  • None of these strategies preserved the patient-centric care fostered by both the NKC and nephrologist
  • Many patient-nephrologist relationships were unnecessarily severed in an attempt to be compliant with CMS guidelines.
  • Relations between NKC and practicing nephrologists deteriorated because CMS requirements for reimbursement placed NKC in the role of enforcer for coverage conditions.
  • Time that could have been spent on direct patient care was consumed by activities required for regulation compliance.
  • Dissatisfaction was high for both patients and nephrologists. Several providers at our institution departed or elected not to care for hemodialysis patients.

Figure 1

Impact of more visits on outcomes

With such adverse consequences to our practice caused by the 2009 CMS coverage condition changes, we wanted to evaluate whether or not patient outcomes improved. Hence, we performed a quality assessment project comparing outcome data of our patients from 2008 and 2010. Since 2009 was the transition year, we waited until nephrologists within our group had incorporated the quarterly dialysis center visits. During this period the focus was still on seeing patients once a month, despite the potential loss of income. The Caremap management was continued without change through 2008 and 2010 so that any differences in outcomes reflected the effect of traveling to dialysis units for the face-to-face dialysis visits.

Methods

Dialysis parameters monitored with the Caremap, emergency room visits, and admissions were reviewed for all hemodialysis patients receiving treatment in 2008 and 2010 at the University of Washington Medical Center. There were 55 patients on hemodialysis in 2008 and 65 patients in 2010. Laboratory data was obtained at least monthly on all patients and more frequently as indicated for clinical conditions. For all analyses we separately compared data for 39 patients who were on hemodialysis in both 2008 and 2010. The Caremap management was the same for all patients, regardless of the nephrologist.

Results

CMS-required visits to dialysis centers to observe patients on dialysis did not affect quality care indicators when the Caremap management system was used (see Figure 1). The distribution of eKt/V, phosphorus, albumin, and hemoglobin test results as a percentage of total tests for all hemodialysis patients in 2008 (before required dialysis visits) and 2010 (after required dialysis visits) were identical. The first four bar graphs in each panel indicate the percentage of times parameters fell within the indicated level. The last two bar graphs of the panel are a reevaluation of the same data indicating the percentage of times parameters were below or above the Caremap goal. Goal targets were as follows: eKt/V >/= 1.2, phosphorus < 5.5, albumin >/= 3.5, hemoglobin within a range of 10-12. Similar results were obtained for patients receiving hemodialysis in both 2008 and 2010.

Figure 2

We next compared the values of our quality care indicators for patients making or not making the targeted goal (see figure 2). Required dialysis center visits did not significantly raise eKt/V or lower phosphorus in patients making the Caremap goal when all patients dialyzing in 2008 were compared with all patients dialyzing in 2010. There was a statistically significant increase in albumin prior to 2009 CMS changes, but the small difference in albumin is unlikely to be of clinical significance. For patients not meeting the targeted goals for hemoglobin, those below goal had statistically significant higher hemoglobin in 2010; those above goal had statistically significant lower hemoglobin in 2010. For the group of patients dialyzed in both 2008 and 2010, data were similar except that hemoglobin values above and below goal were not significantly different (data not shown).

Finding no significant clinical differences in dialysis outcome quality indicators, we then evaluated the number of admissions and emergency department (ED) visits for our hemodialysis population in 2008 and 2010. ED visits and admissions tended to be less, but differences were not statistically significant (data not shown).

Summary

In conclusion, our data show that the 2009 CMS-required quarterly visit to NKC dialysis units to observe patients during treatment sessions did not improve the quality outcome indicators of dialysis adequacy (eKt/V, phosphorus, serum albumin, or hemoglobin) when hemodialysis patients were managed with the Caremap. Additionally, neither admissions nor ED visits were significantly improved. Yet adverse consequences resulted as outlined above.

There is a sad irony in this situation. Seattle was a pioneer in patient centric chronic hemodialysis and leaders at the University of Washington lobbied for federal funding of dialysis. Now CMS mandates are resulting in the demise of our program.

The 2009 CMS coverage conditions were applied to all dialysis patients and nephrologists in the country without regard to existing practice management systems or geography. From a broader perspective, the experiment of mandating a blanket policy without allowing for differences in-patient care management systems which provide equally good, or possibly better, outcomes is a cautionary lesson for single-payer health care systems. Regional input, evaluation of existing management systems, consideration of results like those presented here along with physician reports, could contribute valuable information to policy makers. While we strongly support a single-payer system with less administrative overhead costs, inflexible federal mandates that do not improve clinical outcomes yet negatively impact patient-physician relationships need to be reconsidered.

References

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2. Shamansky SL. A longer-than-usual editorial about population-based managed care. Public Health Nursing 12: 211-212, 1995.

3. Graff  WL, Bensussen-Walls W, Williamson C. Population management in an HMO: new roles for nursing. J.Public Health Nursing 12: 213-221, 1995.

4. Tu A. Presentation to the University of Washington Medical Center administration, 1996.