A view shared of some hopefulness and some pessimism on the state of nephrology
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As I leave my position as Chairperson of the Editorial Advisory Board for Healio/Nephrology News & Issues, I wanted to share my thoughts and concerns on several issues that confront the kidney community.
I have been “around the block” in this specialty, having practiced academic clinical nephrology since 1978 in Portland, Oregon; Louisville, Kentucky; Little Rock, Arkansas; and Nashville, Tennessee, with a 1-year stopover in the United Kingdom’s National Health Service in London.
I served on the Renal Physicians Association’s board of directors for 12 years, and for part of that time, served simultaneously on the board of the American Association of Kidney Patients. I provided input on practice guidelines and at controversy conferences; I have been on national policy committees and have written on these subjects during the last 4 decades.
Kidney health initiative
The kidney care environment may change as a consequence of the Advancing American Kidney Health (AAKH) initiative, but it will be regional in its various forms of implementation. It has a major uphill battle ahead. When I was the chief medical officer for Renal Disease Management in the late 1980s, our group, along with our competitors, sought to organize kidney care delivery systems in an expanding managed care environment.
The model was similar to the Kidney Care Choices demonstration developed by CMS and now underway. Financial incentives were offered, and there is no greater incentive than a global cap paying current rates. But we and our competitors could not successfully replicate the redesigned kidney care delivery systems. Based on that experience, I am pessimistic that the new CMS payment model will be successful and improve care.
Primary care
In many of the venues that I described above, primary care is provided by general practice physicians, physician assistants and advanced practice nurses (APNs). Some of those physicians are family practitioners, some are internists and a scattered few are in other disciplines. The APNs train mostly in family medicine with a few in other disciplines. Hardly any have received special education in caring for kidney diseases. Even those primary care providers trained in internal medicine demonstrate a lack of comfort in providing kidney care.
It goes beyond this. Diabetology guidelines recommend early nephrology referral for proteinuria, GFR decline or difficulty in managing hypertension. Yet those same referring diabetologists expect continued nephrology management once the consultation has been made. So now the patient is seen by a PCP as well as a diabetologist and nephrologist. Often a cardiologist is involved.
There is a physician shortage in some of these disciplines. Here is where the mid-level providers come in. They are not trained to juggle all these consultants, so they want continued subspecialty involvement. Thus, fragmented care is created and perpetuated. The medical home concept is in its infancy and is far from universally accepted.
Patient referral
Social media platforms, electronic health records and the COVID-19 pandemic have gone a long way toward putting space between patients and providers. This becomes relevant when we try to analyze symptoms. Referrals should have triggers like recent guidelines for diabetes suggest. The referrals should rarely result in the transfer of care, yet that is often what happens.
Because of this phenomenon, nephrologists want referral guidelines to be stricter and to occur later in the course. That argument conflicts with the possibility that an early intervention can delay or even prevent the progression of chronic kidney disease. At this time, we lack consensus as to even how to reconcile this problem.
We already know that glycemic control, normalization of blood pressure, relief of obstruction and control of infections promote kidney health. Yet these things are not being done well now. To have separate subspecialists manage these issues further fractionates care. To answer the question as to when a consultation should occur morphs from the medical science area to the social logistical arena. As physicians, we are comfortable with the former and we have little appetite to tackle the latter.
First nephrology referral should occur after a suspicious symptom is noticed, an appropriate pertinent history and physical exam are performed, and initial consistent screening tests are completed. That is not what I experience. What is most common is patients show an elevated serum creatinine without the evaluations I just described, and a nephrology referral is made. Thus, from the start a cohesive standardized referral system has broken down.
Modality education
The timing of modality choice education depends on the rate of disease progression, the relationship the nephrologist has with the patient and family, and the availability of modality educators. Key to this is iteration and discussion. Obviously, hemodialysis as the chosen modality requires advance planning for access creation and maturation.
The components of the AAKH initiative with its payment models are hardly sound on paper, let alone in reality. While there is a push to get more patients on home dialysis and receive transplants, there is a shortage of home dialysis nurses and inadequate fellowship training in home dialysis. As of this writing, Home Dialysis University and the American Society of Nephrology are jointly trying to improve this situation. However, the home dialysis infrastructure will still be insufficient for some time.
This leaves me hopeful but pessimistic. To the kidney community, prove me wrong on the pessimism.
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- Thomas A. Golper, MD, FACP, FASN, recently retired as director of the home dialysis program at Vanderbilt University Medical Center and as chair of the Editorial Advisory Board for Nephrology News & Issues. He can be reached at thomas.golper@vumc.org.
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