Taking a holistic approach to patient care makes sense, but at what point in the timeline of the ESRD patient’s health status can care coordination be most successful? We asked Dugan Maddux, MD, lead author of the paper, “Effects of renal care coordinator case management on outcomes in incident dialysis patients” (Clin Nephrol. 2016 Mar;85(3):152-8). how to identify a “good start” on dialysis and how care coordination can have an influence. Dr. Maddux is vice president of Kidney Disease Initiatives at Fresenius Medical Care North America.
NN&I | The focus of the renal care coordinators in your paper appears to be making sure that patients have a “good start” on dialysis. How do you define “good” or “optimal” start?
Dugan Maddux, MD | “Optimal start” is a term proposed by Mendelssohn, et al. in 2009 1 to replace the terms “planned” and “unplanned” dialysis start. In a BMC Nephrology article, these authors suggested that “suboptimal initiation” of dialysis included patients starting dialysis in the hospital and/or with a central venous catheter and/or not starting with their modality of choice. In contrast, an “optimal start” to dialysis includes a patient starting dialysis electively in an outpatient setting with a mature (usable) permanent vascular access or PD catheter and starting on the patient’s chosen modality.
In simple terms, I consider an “optimal start” as a planned dialysis initiation in the outpatient setting with a usable permanent access. Of note: In 2015, the National Quality Forum (NQF) endorsed, “Optimal End Stage Renal Disease Starts” as an ESRD quality measure. The NQF measure description is: “Optimal End Stage Renal Disease (ESRD) Starts is the percentage of new ESRD patients during the measurement period who experience a planned start of renal replacement therapy by receiving a preemptive kidney transplant, by initiating home dialysis, or by initiating outpatient in-center hemodialysis via arteriovenous fistula or arteriovenous graft.”
NN&I | In our current dialysis delivery approach, what factors influence getting a new ESRD patient to have an optimal start? Is it more focus, more lab tests, more specialized care?
DM | Previous studies have highlighted clinical practices that increase the likelihood that patients will have an “optimal start” to dialysis. 2,3 A major component of suggested best practices is multidisciplinary clinical management for at least six months before dialysis start, including:
- Dietary instruction
- Modality education
- Blood pressure management
- Cardiovascular disease counseling
- Bone and mineral metabolism management
- Hepatitis B vaccination
- Placement of a permanent access
- Transplant referral when possible
- Timely referral to nephrology at least by the time the eGFR is <30 ml/min per 1.73 m2 is required to make this multidisciplinary care possible.
Success in delivering this care has been achieved in health systems that support good population management. Today, electronic health records can facilitate primary care physicians and other specialists, such as cardiologists, in automatically flagging patients with labs and diagnoses consistent with late stage CKD. Identification of these patients improves the likelihood of timely referral to nephrology which is the first step in delivering recommended late-stage CKD care.
Even when timely referral to nephrology is made it is still complex for the nephrology practice multidisciplinary care team to deliver other aspects of recommended late-stage CKD care, such as iterative modality education and support for patients making modality decisions. In addition, care coordination activities are a crucial aspect of timely achievement of a usable permanent access.
NN&I | Clearly, one of these elements is starting dialysis with a permanent vascular access. How much of that “opportunity” is in the control of the typical nephrology multidisciplinary care team?
DM | There are many factors that impact the ability to start dialysis with a usable permanent access.4,6 Many factors that impact pre-dialysis permanent access placement are modifiable, including late referral to nephrology, long appointment wait times for both nephrology and vascular surgery, ongoing permanent access education and decision support, and surveillance for vascular access maturation and maintenance.
Even though modifiable factors are known, it is still challenging to deliver this care in the busy nephrology practice setting. Additional clinical team time, technology, and expertise is needed to track and coordinate care for a late stage CKD patient population.
Studies have shown that an optimal dialysis start is more likely if late-stage CKD patients are seen in the clinic regularly in the six months prior to dialysis start, but it is difficult to ensure that patients are being seen by the clinical team during this “critical period” of pre-dialysis care. 7
It is difficult for a nephrology practice team to know each week who the late-stage CKD patients are and what care and support they need to be prepared to make modality decisions or to be prepared for an optimal dialysis start. Such data-driven care coordination programs like the RCC program improve the likelihood that the right patients will receive the right care at the right time based on current recommended guidelines.
NN&I | Give us a job description of the renal care coordinator within the physician practice. Is there any variability based on the needs of the clinic and its patient population?
DM | As described in this manuscript, the Renal Care Coordinator (RCC) was a case manager resource embedded in the nephrology practice to assist with population management of the late stage CKD patient group. The RCC was supported by weekly reports that tracked the late stage CKD population to coordinate activities recommended for CKD stages 4 and 5 pre-dialysis.
The RCC helped to coordinate CKD and modality education for patients with an eGFR of <30 ml/min per 1.73 m2. These RCCs also provided ongoing support for patients and families to access any information needed to make choices about RRT care, including transplant, dialysis modality selection, or conservative management.
For patients who anticipated starting dialysis, the RCC prompted nephrologists to pursue permanent access type and placement when the eGFR was <20 ml/min per 1.73 m2. RCCs were tasked with making sure PD catheters and permanent vascular accesses were usable and maintained in preparation for dialysis start. The timing of dialysis start remained fully the decision of the nephrologist and the patient. The RCC role included making every effort to enable the patient to have an “optimal” dialysis start when and if dialysis treatment became necessary.
The RCC program had a standard framework for activities and reporting, but embedding the RCC in the local nephrology practice enabled the RCC to function in concert with the practitioners and resources within the local environment. It also created the opportunity for face to face encounters with patients and families to establish working partnerships.
This experience with an embedded RCC met goals of improving processes that lead to an increased likelihood of an optimal start to dialysis, but it is possible that other case management models may achieve similar goals. The services that improve outcomes have been well described, so sustainable models should be developed that can deliver these services for all patients who need them based on guideline recommendations.
NN&I | Anything in particular that you feel are important qualifications for the RCC? It sounds like, based on the paper, that general nursing background has a higher priority than dialysis nursing. Explain.
DM | Clinicians working in the original RCC program typically had a nursing background. Some clinicians had dialysis experience or interventional nephrology experience, but this was not a requirement. Being familiar with what patients might experience during dialysis and being knowledgeable about modalities and permanent PD or vascular access was important. Many RCC activities involved use of excellent communication skills both with patients and families and with the remainder of the clinical team.
NN&I | Tell us what is in the weekly workflow report that the RCC gets.
DM | The Weekly Workflow Report was designed to help the RCC track the CKD 4 and 5 patient population within the nephrology practice. Based on recommended care for late stage CKD patients, this report noted whether patients who were due for CKD education had received it and if patients and families had made a decision about treatment options, including renal transplant, dialysis, or conservative care. If patients had an eGFR <20 ml/min per 1.73 m2 and planned to start a dialysis therapy, then the report provided tracking of appointments for permanent access placement, usability and maintenance.
The Weekly Workflow Report was generated from business and clinical systems of the nephrology practice. Data was collected in the nephrology practice electronic health record as part of usual patient care and communication. Fresenius Medical Care North America (FMCNA) analytics teams, in partnership with nephrology practice administrative staff, developed methods for clinical data extraction and reporting.
NN&I | Why does the RCC’s job end once dialysis commences?
DM | The role of the RCC is to support every opportunity for late stage CKD patients to receive CKD and modality education, to assist them to work with the clinical care team to have enough information and time to make choices about treatment options, and to improve the likelihood that a patient who needs to start dialysis will have an “optimal start.” These are all activities focused on CKD care and transition support for patients who are starting dialysis treatment. Once a patient starts dialysis, the facility multidisciplinary team is there to provide support.
NN&I | Tell us how you think the RCC can impact improvements in faster placement of a permanent access.
DM | The RCC is a single point of contact for various members of the care team and for the patient. The RCC serves as a focal point for communication which streamlines scheduling appointments and communicating clinical information among stakeholders including the interventional or surgical care team, the nephrology clinic team, and the patient.
In addition, the weekly population management tools improve the likelihood that the RCC will be aware of a problem or missed appointment in a timely manner.
NN&I | How does the RCC inter-relate with the nursing staff in a clinic? Coming from the physician practice side, the coordinators do not provide any direct patient care.
DM | The RCC provides case manager and care coordination support and does not provide direct patient care. Management of a late stage CKD population of up to 500 patients requires data and communication management skills and activities which support and enable the clinical team in providing the appropriate clinical care. The embedded RCC can use usual nephrology practice communication methods to provide feedback, messages, or alerts as needed to the remainder of the clinical team.
NN&I | There has been some debate about how early start on dialysis can do more harm than good. Your data shows RCC-monitored patients started “significantly earlier” than your non-RCC patients. Is that part of the objective of this approach?
DM | Figure 2 in the manuscript shows the time to first outpatient Fresenius dialysis from first ever chronic dialysis. This Kaplan-Meier curve shows that patients who were part of the RCC program were more likely to start dialysis as an outpatient and have fewer hospital days at the start of dialysis compared to patients not in the RCC program. This does not relate at all to the timing of dialysis start relative to eGFR or symptoms. In the RCC program, the decision to start dialysis was entirely a decision between the nephrologist and patient and was not part of the data collection or program activity.
NN&I | Give us a synopsis of the results: How were RCC-managed patients better off than the controls in this study?
DM | Patients enrolled in the RCC program were more likely to start dialysis in the outpatient setting. Propensity matched RCC patients were more likely to start dialysis on PD and more likely to start HD with a usable permanent access than the matched cohort.
In association with late stage CKD case management and an optimal dialysis start, patients in the RCC program had fewer hospital admissions and hospital days in the first 120 days of dialysis compared to propensity matched controls. This is consistent with literature that suggests that “optimal preparation” in late stage CKD and an “optimal start” to dialysis improve dialysis outcomes in the first year of treatment.2,3,6,7
- Mendelssohn DC, Malmberg C, Hamandi B. An integrated review of “unplanned” dialysis initiation: reframing the terminology to “suboptimal” initiation. BMC Nephrol. 2009;10:22.
- Narva AS. Optimal preparation for ESRD. Clin J Am Soc Nephrol. 2009;4 Suppl 1:S110-3.
- Saggi SJ, Allon M, Bernardini J, Kalantar-Zadeh K, Shaffer R, Mehrotra R, et al. Considerations in the optimal preparation of patients for dialysis. Nat Rev Nephrol. 2012;8(7):381-9.
- Hakim RM, Himmelfarb J. Hemodialysis access failure: a call to action–revisited. Kidney Int. 2009;76(10):1040-8.
- Lopez-Vargas PA, Craig JC, Gallagher MP, Walker RG, Snelling PL, Pedagogos E, et al. Barriers to timely arteriovenous fistula creation: a study of providers and patients. Am J Kidney Dis. 2011;57(6):873-82.
- Hughes SA, Mendelssohn JG, Tobe SW, McFarlane PA, Mendelssohn DC. Factors associated with suboptimal initiation of dialysis despite early nephrologist referral. Nephrol Dial Transplant. 2013;28(2):392-7.
- Singhal R, Hux JE, Alibhai SM, Oliver MJ. Inadequate predialysis care and mortality after initiation of renal replacement therapy. Kidney Int. 2014.