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Showing papers in "Nephrology news & issues in 2015"


Journal Article
TL;DR: This program is designed to enhance skills in the areas of medical, emotional, and role management in patients with ESRD undergoing conventional hemodialysis to benefit patients' outcomes and quality of life.
Abstract: A strong emphasis on self-management for health maintenance in a variety of chronic diseases has been shown to benefit patients' outcomes and quality of life. However, little has been published on such programs in patients with chronic kidney disease. We studied the feasibility and effectiveness of the Chronic Disease Self-Management Program (CDSMP) in 14 patients with ESRD undergoing conventional hemodialysis. This program is designed to enhance skills in the areas of medical, emotional, and role management. Outcome measures in health status, self-management behaviors, self-efficacy, and health care utilization were evaluated through use of questionnaires at baseline and after six months.

21 citations


Journal Article
TL;DR: It is found that up to 40% of patients experienced an improvement in their blood pressure profile over the period of the study, suggesting that simple changes to dialysis prescription can result in a significant reduction in the incidence of intradialytic hypotension.
Abstract: Intradialytic hypotension is defined as a decrease in systolic blood pressure by ≥ 20 mm Hg or a decrease in mean arterial pressure by 10 mm Hg, and is associated with symptoms that include abdominal discomfort, yawning, sighing, nausea, vomiting, muscle cramps, restlessness, dizziness or fainting, and anxiety. The incidence of a symptomatic reduction in blood pressure during (or immediately following) dialysis ranges from 15-50% of dialysis sessions. It is a major cause for morbidity in elderly hemodialysis patients and those with cardiovascular compromise. It impairs patient well-being, limits ultrafiltration, and increases the risk for coronary and cerebral ischemic events as well as vascular access thrombosis. Several studies have shown a poorer survival in dialysis patients who experience frequent hypotensive episodes on dialysis as opposed to those who do not. In our outpatient dialysis unit, we identified that 9% of our dialysis patients experienced a decrease in their systolic blood pressure to below 80 during dialysis. The purpose of this quality improvement project was to study the factors associated with intradialytic hypotension in these patients and institute appropriate measures to mitigate this issue. Another aim was to educate the dialysis staff on how to manage these patients. Patients were selected using data from weekly rounding reports and orders were written for interventions including ultrafiltration profiling, cool (36 degrees C) dialysate, weight-based ultrafiltration, etc. Outcomes were studied over a period of 3 months. We found that up to 40% of patients experienced an improvement in their blood pressure profile over the period of the study, suggesting that simple changes to dialysis prescription can result in a significant reduction in the incidence of intradialytic hypotension.

10 citations


Journal Article
TL;DR: Regardless of one's view on unauthorized aliens and health care benefits, states will continue to wrestle with the constraints imposed by federal law and the types of benefits they are willing to provide to this population through state funding.
Abstract: Regardless of one's view on unauthorized aliens and health care benefits, states will continue to wrestle with the constraints imposed by federal law and the types of benefits they are willing to provide to this population through state funding.

3 citations


Journal Article
TL;DR: Critical challenges remain before the full potential of iPS cells can be accurately assessed, and it is hoped that new, more effective and less expensive modalities for renal replacement therapy will occur in the foreseeable future.
Abstract: iPS cells from patients with kidney disease are a new tool with the potential to impact the future of renal care. They can be used in the laboratory to model the pathophysiology of human kidney disease, and have the potential to establish a new area of immunocompatible, on-demand renal transplantation. Critical challenges remain before the full potential of these cells can be accurately assessed. We need to understand whether the derived cell types are mature and can replace kidney function(s). To what extent can iPS cells model kidney disease in the simplified environment of cell culture? Ultimately, successful integration of these cells as autograft therapies will require demonstration of safety and efficacy equal or superior to the existing gold standards of kidney allograft transplantation and dialysis. Specific educational and infrastructural changes will be necessary if these specialized technologies are to be adopted as an accepted modalities in clinical medicine. Given these barriers, the first fruit of these labors is likely to be improved understanding of pathophysiological pathways in human IPS cell disease models, followed by drug discovery and testing. These experiments will lead naturally to improvements in differentiation and experiments in animal models testing function. The time course to achieve the desired goals remains unknown, but the ultimate hope is that new, more effective and less expensive modalities for renal replacement therapy will occur in the foreseeable future. A new standard of care for patients is anticipated that addresses limitations of currently available treatments.

3 citations


Journal Article
TL;DR: This report conducted the first national study to examine patient safety in nephrology nurse practice settings and accentuated the need to develop a culture that encourages all health care providers—regardless of position and profession—to advocate for patient safety and to question practices that place patients at risk for harm.
Abstract: Introduction What does safety look like in your nephrology practice setting? Do you feel comfortable reporting errors, near-misses, and unsafe conditions? Do you believe your patients perceive they are safe in the dialysis, peritoneal, transplant, or nephrology clinic setting? Do you work with other health care team members to ensure patient safety at all costs? Safety is the responsibility of every person working in your nephrology practice setting. Reporting errors, nearmisses, and unsafe conditions and practices is the responsibility of every employee and provider because mistakes are made every day in the health care environment. This was recognized 15 years ago when To Err Is Human: Building a Safer Health System (2000) was published by the Institute of Medicine (IOM). This cutting-edge report emphasized the responsibility of health care providers to examine faulty systems and processes within their organizations with the goal of improving patient clinical outcomes. This report also accentuated the need to develop a culture that encourages all health care providers—regardless of position and profession—to advocate for patient safety and to question practices that place patients at risk for harm. Since the time of the IOM report, significant attention has been given to defining the terms of patient safety culture and climate, developing tools to measure these components, and conducting research to establish the relationship between safety culture/climate and patient outcomes (DiCuccio, 2014). In an era that places safety at the forefront of health care in nearly all practice settings, a study of patient safety culture in nephrology nurse practice settings had not been conducted. Nephrology nurse practice settings utilize highly technical equipment in a fast-paced environment, and studying safety and safety culture was long overdue. In 2014, we conducted the first national study to examine patient safety in nephrology nurse practice settings (Ulrich & Kear, 2014a).

2 citations


Journal Article
TL;DR: Patients treated with daily home hemodialysis had lower monthly mortality rates and generally improved health status compared to patients treated with conventional dialysis.
Abstract: Nursing home patients on dialysis are higher-acuity compared to the broader end-stage renal disease population, and historically have poor outcomes. The objective of this epidemiological study was to compare outcomes in ESRD patients in the nursing home setting treated with daily home hemodialysis versus conventional three-day-a-week hemodialysis. Health status was evaluated for 3,919 patients (n=3391 conventional, n=528 daily home dialysis; April 2007 to June 2013 for conventional; April 2011 to June 2013 for daily home hemodialysis). Analyses included monthly mortality rates, Kaplan-Meier survival analysis, and laboratory values. Results showed monthly mortality rates were consistently lower in the daily home hemodialysis population over the same time period vs. conventional dialysis care. In the incident three months of treatment, annualized monthly mortality rates were 70%, 72%, and 64% in the conventional dialysis population vs. 50%, 24%, and 17% in the daily home population. Patients treated with daily home dialysis had generally similar or higher albumin and hemoglobin values and lower ferritin values over the same time period. Patients treated with daily home hemodialysis had lower monthly mortality rates and generally improved health status compared to patients treated with conventional dialysis. The results of this study are provocative and should be evaluated in a prospective study.

2 citations


Journal Article
TL;DR: The analysis of this benchmarking data tells us that successful nephrology practices will likely be larger, more sophisticated and tightly aligned with all stakeholders in the pursuit to provide high quality, low cost care to patients with kidney disease.
Abstract: The analysis of this benchmarking data tells us several things. Nephrology practices are more complex. Physicians are generating more RVUs for less money and a greater percentage of income is coming from things other than direct patient care. Practices have responded partly by becoming larger and looking for revenue stream diversification. The ability to predict the financial future from the historical data is problematic. We know from the most recent survey that a significant number of nephrology practices are already participating in accountable care organizations, shared savings programs, and even risk sharing contracts. We know that the incentive for participation in government quality reporting programs and meaningful use is transitioning from the carrot to the stick and that reductions in reimbursement will be applied to those who are unsuccessful. In order to take on the challenges and complexity that the future holds, successful nephrology practices will likely be larger, more sophisticated and tightly aligned with all stakeholders in the pursuit to provide high quality, low cost care to patients with kidney disease.

2 citations


Journal Article
TL;DR: Good vascular access continues to be a cornerstone of optimal hemodialysis (HD) for patients with endstage renal disease and central venous catheters (CVC) are most frequently used to establish the initial vascular access in ESRD patients requiring HD.
Abstract: Good vascular access continues to be a cornerstone of optimal hemodialysis (HD) for patients with endstage renal disease. Central venous catheters (CVC) are most frequently used to establish the initial vascular access in ESRD patients requiring HD. Data from the most recent United States Renal Data System (USRDS) report indicates that the use of CVCs continues to be as high as 80% in new ESRD patients requiring HD. However, CVC use is associated with inflammation, infection, thrombosis, stenosis, and catheter malfunction, which leads to significant morbidity and mortality in HD patients. 1-3,5,7 Avoidance of catheters as the initial and ongoing vascular access has been advocated to reduce the high burden of catheterdriven complications. Despite the high patient morbidity and mortality, the use of CVC is not reduced for vascular access. Clinical characteristics of patients, social situation, financial circumstances, and practice processes dictate both the dialysis modality and the type of HD vascular access used. Practice process issues include delayed referral to nephrologists, an inadequate pre-HD preparation time, and poor access to surgery to create other types of vascular access such as arteriovenous fistulae (AVF) and arteriovenous grafts (AVG). The USRDS data also suggest that, among HD patients who received care from a nephrologist for more than a year before starting dialysis, more than 40% initiated dialysis with a CVC. On the other hand, 43% of patients starting ESRD therapy who had not seen a nephrologist before initiation had to start dialysis with CVC.

1 citations


Journal Article
TL;DR: The Renal ACO: New Approaches to Kidney Care will highlight ideas from three providers on how they are improving the quality of care in their organizations, and two of the three, Dialysis Clinic Inc. and the Centers for Dialysis Care, are participating in the demonstration.
Abstract: Editor’s Note: After nearly a year and a half of rewrites and recalculations, the Centers for Medicare & Medicaid Services appears ready to launch the Comprehensive ESRD Care Initiative, a five-year demonstration using accountable care organization principles to determine if placing dialysis providers and nephrologists in charge of all aspects of a patient’s medical needs will improve quality and save money. At the core of this ACO model will be ESRD “Seamless Care Organizations” that will coordinate the care, manage the array of specialists and, if all goes well, divide up the health care savings under the new system. This new series in NN&I—The Renal ACO: New Approaches to Kidney Care—will highlight ideas from three providers on how they are improving the quality of care in their organizations. Two of the three, Dialysis Clinic Inc. and the Centers for Dialysis Care, are participating in the demonstration. The lessons learned by these providers are all applicable to the goal of the ESCOs. Look for these articles and other news posted online about progress during the renal ACO demonstration at www.nephrologynews.com/aco.

1 citations


Journal Article
TL;DR: The new social work service delivery systems described in this article are sure to help the industry reach its goals to keep care patient-centered while maintaining quality and reducing the costs of treating end stage renal disease.
Abstract: Integrated care has brought changes to the field of nephrology social work. In turn, nephrology social work has brought innovative contributions to the field of integrated care. The new social work service delivery systems described in this article are sure to help the industry reach its goals to keep care patient-centered while maintaining quality and reducing the costs of treating end stage renal disease. Social workers are called to serve the needs of the client, the family, the community and the society at large. Nephrology social workers are right where they belong in the ESRD integrated care environment. They feel right at home.

1 citations


Journal Article
TL;DR: Medication compliance among individuals with hypertension symbolizes a growing concern within the medical community and solutions to this problem must be multifactorial.
Abstract: Medication compliance among individuals with hypertension symbolizes a growing concern within the medical community. It is said that roughly 50% of hypertensive patients in the United States do not comply with their medication regimen. Uncontrolled hypertension in turn can lead to kidney failure and other complications. Because compliance to medication regimens is complex and difficult to ascertain, solutions to this problem must be multifactorial.



Journal Article
TL;DR: Understanding the perceptions of technicians regarding the benefits of certification and the limitations of workplace incentives should enable employers to improve their recruitment and retention programs.
Abstract: The Nephrology Nursing Certification Commission initiated this research project to study the viewpoint of dialysis technicians regarding the value of certification. A national convenience sample was obtained using both paper-and-pencil and online forms of the survey instrument. Demographic characteristics were obtained concerning age, race, ethnicity, education, and future employment planning. Technicians' primary work settings, the roles they fill, and the types of certification they hold are described. Incentives offered by employers are considered to explore how they contribute to job satisfaction. Understanding the perceptions of technicians regarding the benefits of certification and the limitations of workplace incentives should enable employers to improve their recruitment and retention programs. Information obtained may offer a baseline for future observations of the characteristics of these significant and essential contributors to the nephrology workforce.

Journal Article
TL;DR: It is important for providers and practices to begin working with registry level data, as PQRS data is the basis for the value based modifier now and MIPS- related quality data after 2018.
Abstract: It is important for providers and practices to begin working with registry level data. Submitting data to a qualified clinical data registry currently satisfies Meaningful Use Stage II menu set items. In the future, with the rollout of MIPS and the increasing focus on sharing risk, registry data will be used as a benchmark for both publicly-reported performance (the physician compare program will be linked to provider-level QCDR data) and modifications to reimbursement. It is important to remember that PQRS data is the basis for the value based modifier now and MIPS- related quality data after 2018. The RPA has launched and is evolving a unique and versatile nephrology-specific data collection and analytics tool. In collaboration with the American Society of Diagnostic and Interventional Nephrology, vascular access measures will be added to the registry for 2016. The registry and the analytics platform is a tier of software operating above your practice management system and EHR and, if data can be obtained, it can span all the locations in which nephrologists provide care.




Journal Article
TL;DR: Physical exam and clinical evaluation remain key in detecting access problems and a surveillance method chosen by the clinic can provide early identification of stenosis allowing for timely intervention of access dysfunction.
Abstract: The physical exam, the clinical assessment, along with the surveillance tool we use has provided us the ability to identify access problems or potential problems. Abnormal surveillance data is always correlated with physical exam and clinical findings to determine the need for intervention. Monitoring and surveillance of vascular access are an integral part of the care of the hemodialysis patient. There are different techniques and methods available for identifying access dysfunction. Despite multiple studies that have been performed, there is still no consensus as to the best methodology to use. Physical exam and clinical evaluation remain key in detecting access problems. This along with a surveillance method chosen by the clinic can provide early identification of stenosis allowing for timely intervention of access dysfunction.

Journal Article
TL;DR: Patients who were enrolled in an MA plan upon initiation ofdialysis had a 9% lower mortality rate than their MFFS counterparts, and this beneficial association of MA enrollment was found to be sustained over the first two years of dialysis treatment.
Abstract: Physicians across the care continuum are increasingly aligned around the belief that coordinated care can improve patient outcomes. As the principal caregivers for one of the most medically fragile patient groups in healthcare, nephrologists are especially attuned to the potential value of integrated care. Medicare Advantage (MA) offers one way to test this hypothesis. By law, end-stage renal disease patients currently cannot enroll into an MA plan, but if they develop ESRD while in such a plan, they may continue to be enrolled. The contrast between these patients and their counterparts who carry Medicare fee for service (MFFS) thereby represents a natural experiment that affords an opportunity to examine whether enrollment in a coordinated care system may improve outcomes. In order to promote (unbiased) comparison of patients in a non-randomized context, we propensity score-matched incident dialysis patients enrolled in MA versus those in MFFS. The data demonstrate that patients who were enrolled in an MA plan upon initiation of dialysis had a 9% lower mortality rate than their MFFS counterparts. This beneficial association of MA enrollment was found to be sustained over the first two years of dialysis treatment.



Journal Article
TL;DR: Without an increase in base pay rates for both staff and travel nurses and rethinking some hard and fast practices, there will be no improvement in the dialysis nursing landscape in the foreseeable future.
Abstract: Summary Without an increase in base pay rates for both staff and travel nurses and rethinking some hard and fast practices, there will be no improvement in the dialysis nursing landscape in the foreseeable future.

Journal Article
TL;DR: In thirty-three patients included in the analysis, significantly fewer bacteremia events and a significantly increased number of vascular interventions were reported for the HeRO versus Control group.
Abstract: The Hemodialysis Reliable Outflow (HeRO) graft was compared to the cuffed catheter in end-stage renal disease patients. All consented patients were evaluated for HeRO graft placement. Eligible patients that did not receive a graft were enrolled in the control group. Participants who had not exhausted peripheral venous access sites suitable for fistulas and grafts were excluded. Differences in quality of life and incidence of bacteremia, vascular interventions, hospitalizations, and death were evaluated over one year. In thirty-three patients included in the analysis--16 HeRO, 17 control--significantly fewer bacteremia events (93.8% vs. 64.7%) and a significantly increased number of vascular interventions (64.7% vs. 25%) were reported for the HeRO versus Control group. The increased interventions in the HeRO group may be due to the two-step placement process.