Practices can improve efficiency with a blend of nephrologists, advanced practitioners
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Results from the 2020 nephrology fellowship match for appointment year 2021 show a robust increase in filled fellowship slots, increasing to 73% compared with 62% in the previous year.
It is likely too early to tell whether this represents an ongoing trend away from the stagnation seen in nephrology in the last decade.1
A decreased interest in nephrology fellowships began in 2011 and has trended downward during the last 7 years in the low 60% range with little improvement. Given an unfilled fellowship position slot rate still exceeding 25%, one reasonable response to this finding would be to simply recommend a decrease in the number of fellowship training spots.
Yet there remains one critical problem: there remains one critical problem: The nephrology community is facing a shortage of nephrologists in the setting of increased patient demand. While the latest CMS data indicates the COVID-19 pandemic led to a temporary decrease in incident cases of end-stage kidney disease for the first time in memory, there remain more than 785,000 patients with prevalent ESKD and approximately 50 million people with impaired estimated glomerular filtration rate and/or proteinuria in the United States.2,3
There are many reasons for the declining interest in nephrology. It is recognized as one of the more academically challenging subspecialties in internal medicine with a demanding work schedule. The monetary benefits are not offset by the demands of the specialty.
When factored into the more recent data indicating declining wages and the challenges of advanced alternative payment models (such as the current ESRD Treatment Choices model that involves 30% of all dialysis clinics), it is understandable why many internal medicine residents are considering other subspecialty fellowship training options.4
Role of APs
From a historical perspective, advanced practitioners (APs; nurse practitioners and physician associates) became a common part of nephrology practices in 2004. That year, CMS adjusted reimbursement for the care of dialysis patients to a monthly capitated payment (MCP) system which increased the frequency of dialysis visits required to achieve maximal compensation.5 A report analyzing U.S. nephrology AP survey data from 2010 to 2020 by Zuber and colleagues showed 75% of nephrology practices in the United States had employed at least one AP by 2013.6 The same survey reported that 86% to 88% of APs were involved in hemodialysis rounds and approximately 53% of their time was spent providing dialysis care, with only 14% of time spent providing hospital-based care.
The experienced nephrologist is exposed to numerous demands coming from many directions. Whereas many nephrologists once could rely on renal fellows for more urgent inpatient needs, the declining trainee workforce has created critical voids in hospital-based medical care.
Taking into consideration the growing demand for meeting the goals of dialysis quality and the new advanced alternative payment models, APs may be exactly what the doctor ordered: more timely inpatient consultation, management of complex dialysis patients with early ED interventions to avoid unnecessary hospital admissions, avoidance of potentially harmful blood transfusions, continuation/reconciliation of outpatient medications, and frequent interactions with hospitalists and case managers to provide safe transitions of care.
These are all areas that most nephrologists (and renal fellows) would readily admit they cannot satisfy when it comes to the hierarchy of demands placed upon them with their daily workload. APs could be the answer to many of these challenges.
Nephro-hospitalist
We began adopting a model of integrating APs into our practice approximately 4 years ago. At that time, we had a seasoned nurse practitioner (NP) who had worked with our transplant/dialysis access surgeons performing outpatient vessel mapping and perioperative care, in addition to some outpatient hemodialysis rounding duties.
The addition of four more advanced practitioners (one NP and three PAs) since that time has not only broadened our nephrologists’ flexibility, but also enriched our APs’ work exposure. We now utilize two of our APs as “nephro-hospitalists” in a 715-bed tertiary care medical center where they care for both patients with ESKD and general nephrology consult patients. They also participate in team rounds and education with our renal fellowship program. While they perform initial visits and follow-up care with our nephrologists for a wide array of nephrology patients, they also focus much of their time communicating with case managers and outpatient dialysis units in efforts to maximize safe transitions of care. Part of our future directional goals include training APs with regard to point of care ultrasound use and support for renal biopsy and central line placement.
On the receiving end of our acute hospital program, we have another AP who provides care in local nursing homes and rehabilitation facilities (discharge destinations that are commonly seen as high risk for hospital readmissions) while also helping manage a pre-dialysis advanced chronic kidney disease outpatient clinic. Our last AP has shown a determined interest in immunology and found himself supporting our outpatient transplant clinic and our home dialysis program. All APs in our practice provide some form of outpatient dialysis support (typically rounding on two of four shifts per month for patients they share with a dedicated nephrologist) that takes up less than 20% of their clinical time.
Long-term learning
As part of our effort to maintain AP satisfaction and engagement in nephrology, we have developed a program for long-term learning that gives them opportunities to build on their knowledge of renal disease. Whether it be acute glomerulonephritis, management of regional citrate anticoagulation during continuous renal replacement therapy, basic immunology or palliative care, our inpatient APs are expected to take part in fellowship-level lectures, as well as a weekly sit-down session to meet with a nephrologist and discuss challenging cases. Some of our APs have also taken an interest in participating in our research endeavors.
Lastly, our APs have a monthly lunch meeting with our group president to discuss any particular challenges they may be experiencing and also to learn more about the goals and future directions of the practice. Ultimately, by having our APs participating in the same nephrology experiences their nephrology physician mentors find so rewarding, we hope to build long-term relationships with our APs rather than creating a “revolving door” of high AP turnover, which can be costly from a financial, emotional and time-management perspective.
The nephrology community has long been known as a stalwart in taking care of chronically ill patients, but now must also innovate in such areas as value-based care, the building of its workforce and proving itself to be more flexible in times of resource strain to lead medicine once again to better care of our patients.
APs have proven to be a talented, energetic and inspiring group that nephrology must not ignore. They not only deserve our attention, but also our dedication to help incorporate them as part of our long-term multidisciplinary nephrology team.
Author’s note: In the opening paragraph, 2020 refers to the year of nephrology fellow matriculation to the nephrology program, which was the result of the 2020 nephrology fellowship match.
- References:
- Pivert K. AY 2021 nephrology match. ASN;2021. Available at https://data.asn-online.org/briefs/09_ay-2021-match.
- www.healio.com/news/nephrology/20210416/allcause-mortality-increased-among-patients-on-dialysis-transplant-recipients-in-2020
- United States Renal Data System. 2020 USRDS annual data report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Md., 2020.
- Salsberg E, et al. The U.S. nephrology workforce 2015 developments and trends. ASN;2015. Available at: www.asnonline.org/education/training/workforce/Nephrology_Workforce_Study_Report_2016_Summary.pdf.
- Nair D, et al. BMC Nephrol. 2019;doi:10.1186/s12882-019-1289-y.
- Davis J, et al. JAAPA. 2021;doi:10.1097/01.JAA.0000723944.52480.d8.
- For more information:
- Brittany Chew, NP, and Ann Hinckley, NP, are employees of Kidney Care & Transplant Services of New England in Springfield, Massachusetts.
- Daniel Landry, DO, FASN, is chief of the division of nephrology and medical director of inpatient dialysis and critical care nephrology at the University of Massachusetts Medical School-Baystate in Springfield, Massachusetts. He is a partner in private practice for Kidney Care & Transplant Services of New England.
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