On June 23, Martin Schreiber Jr., MD, began his new position as vice president of clinical affairs for home modalities at DaVita Kidney Care. He came from Cleveland Clinic, where he had previously served as chairman of the Department of Nephrology and Hypertension and the Director of Home Dialysis. “I believe that every patient deserves to be educated on their modality options and to have a choice in their dialysis care," said Schreiber in a prepared statement. "While home dialysis may not be right for everyone, we recognize that many patients could benefit from more frequent dialysis and enjoy a higher quality of life with the option of a home modality."
NN&I asked Schreiber about his approach to increasing the use of home therapies among DaVita Kidney Care’s 166,000 dialysis patients, of which just over 20,000 were on either peritoneal dialysis or home hemodialysis in 2014.
NN&I: How do you think this job will differ from your work in home dialysis at the Cleveland Clinic?
Schreiber: While I have immensely enjoyed my clinical and leadership roles at Cleveland Clinic, I now have an opportunity at DaVita Kidney Care to shape a new vision of how the home will become the cornerstone for kidney disease treatment in the future.
NN&I: Will you take the same approach, only on a much larger stage?
Schreiber: Both organizations have strong traditions and culture for patient-focused care and innovative approaches to achieving superior outcomes. My goals, whether as chairman at Cleveland Clinic or now as VP of Medical Affairs at DaVita Kidney Care, are to develop a special team that re-imagines ESRD care in the US., exudes a “can do” attitude, and constantly strives for excellence in the patient care experience.
NN&I: At 12.4%, DaVita Kidney Care has the highest percentage of home patients among the three largest dialysis providers in the US. But there is a sense that recent growth in home modalities appears to be driven more so by financial incentives in the Medicare bundled payment than by a change in physician attitudes toward home therapy. Do you agree?
Schreiber: While the bundle most likely has had an impact, I believe physicians are now beginning to focus on how you sequence ESRD treatment options to achieve the longest quality survival. Even though transplant remains the superior option for a significant percentage of patients, timely transplant from a living related donor is not always feasible. Developing a patient‘s life plan by leveraging home dialysis options is key to improving ESRD treatment results.
NN&I: Should we set a target for the percentage of patients on home therapy in this country?
Schreiber:As we become more comfortable with caring for patients on home dialysis the percentage on home dialysis will increase. It is difficult to set a specific target but in-center hemodialysis should not remain the default therapy for US ESRD patients in the future. Patients should be educated on their modality choices and, with the help of their doctor, choose the optimal therapy for their life.
NN&I: Do you have a goal for placing patients at home at DaVita?
Schreiber: Our goal is to optimize the care of patients at home and grow the therapy numbers by achieving superior outcome results.
NN&I: You have done some work with Peritoneal Dialysis International, suggesting you may favor PD over home hemodialysis as a home modality choice. What are your thoughts?
Schreiber: The question shouldn’t be is HHD or PD better for a patient but rather what sequence should therapies be applied to achieve the longest quality survival; in some cases it is HHD, in others it will be PD. When possible, home should be the first option in the continuum of ESRD care.
NN&I: How would you explain the advantages and disadvantages of both modalities to a patient?
Schreiber: In most cases HHD necessitates a partner or care giver to assist in the treatment, whereas there is less dependence on a partner for patients on PD. While HHD requires a functioning vascular access, on PD the vascular access can be preserved for a future time point. Both therapies provide the potential for excellent results, depending on the need of the patient. Patients need to view modality selection with the long term in mind and understand how the decision for a specific modality they make today can affect their outcomes years from now. If you have kidney failure, the appropriate sequencing of dialysis therapies is key to longevity.
NN&I: Many home dialysis advocates argue that the low numbers of patients dialyzing at home has to do with poor educational opportunities for nephrologists in the early days of their career, i.e., little training in medical school other than about the standard: in-center hemodialysis. What educational initiatives will help promote home dialysis for DaVita Kidney Care, both internally among its own nephrologists and clinical staff, and externally, through professional organizations and at conferences?
Schreiber: Physician decisions impact patient survival and certain decisions can impart risk to the patient that adversely affects outcomes. With the reimbursement focus shifting to value-based health care built on costs, quality and outcomes, physicians will look more closely at what decisions they make with their patients. Instead of educational activities solely discussing treatment option differences, there will be a shift to helping physicians better understand how individualized treatment plans can lower cost, deliver higher quality results and improve outcomes.
And how do we change the curriculum about dialysis in medical schools? The field of nephrology is not attracting the numbers of residents and fellows it has in the past. And yet nephrology remains an exciting and fulfilling specialty with great opportunities and academic challenges. The first step in improving the dialysis curriculum is to increase the numbers of quality trainees going into nephrology and then making ESRD care a key pillar in nephrology education.
NN&I: Any special initiatives or programs you plan to launch at DaVita Kidney Care to stimulate growth in home dialysis?
Schreiber: My main focus over the first several months is getting familiar with the different areas within DaVita Kidney Care and developing those relationships which will be critical to moving the home area forward. I envision a number of new initiatives, which will reshape home dialysis as we know it today, setting the stage for increased clinical acceptance, innovative patient monitoring, and truly re-imagining what we can accomplish in the home setting that will drive superior results.