Kenneth A. Liss, DO-
In the last edition of this journal, Dr. Singh referenced some troubling statistics that many of us in the nephrologic community are already keenly aware.1 Simply, the chronic kidney disease population rapidly grows while the number of quality healthcare professionals able to provide care plummets. In order to attract both the “best and the brightest,” Dr. Singh advocates for a more interesting nephrology curriculum at both the medical school and residency level. I have also heard complaints from colleagues that much of renal therapies and technologies have been stagnant over the past few decades and that capable physicians want to direct their energies elsewhere. This sense of frustration may sometimes get conveyed to our students and residents on hospital rounds. When faced with a career choice that includes the challenge of caring for chronically ill patients who rarely see improved health, physicians in training may think twice before choosing nephrology. Collectively, nephrologists who generally take great pride in being able to provide comprehensive care to their patients would be best served channeling their efforts to a few core issues. Chief among these should be improved renal replacement therapies with an emphasis on home modalities and improving our mortality data. The net result will save healthcare dollars, improve the quality of our patients’ lives, and give our specialty a renewed sense of purpose.
Despite the relatively small volume of dialysis patients, the end-stage renal disease (ESRD) population is responsible for 11% of Medicare dollars spent annually. In addition, despite frequent encounters with nephrologists and physician extenders, fistula first initiatives, a better understanding of bone and mineral disease, and expanded transplant programs, morbidity and mortality data are still disappointing. The developed world continues to lag behind the developing world in home dialysis delivery.2 The reasons for this are complex but, likely center around ease of delivery of in-center therapy, lack of patient education, and financial disincentive to home therapy. Although bundling may slowly erode the financial incentive for in-center treatment I believe we as clinicians should be able to promise our patients equivalent or better care at a smaller cost. This can occur if we encourage our patients to choose a home modality.
There are myriad examples throughout the United States where motivated nephrologists, utilizing increased educational resources, are able to dialyze a significantly higher percentage of their ESRD patients using home modalities. It is also my anecdotal experience that both patients and nephrologists are more satisfied with the relationship afforded when patients choose a home therapy. It is almost universal that nephrologists convey fatigue over the non-compliance, litany of complaints, and general lack of well being that is often present in our in-center population. Conversely home patients retain residual renal function longer, typically are more compliant, and often enjoy better quality-of-life measures than their in-center counterparts.3 For the most part this care can also be delivered at a significantly lower cost.
A concerted effort should be made to emphasize home treatments. Goals should be set to achieve a realistic change in the current balance over the next decade. Additionally nephrologists should be rewarded for the training and effort needed to exact this change. It may also be a consideration to incentivize patients and families who make this choice through tax credits so they can be responsible for how their healthcare dollar is spent.
I believe that nephrologists in the United States should be able to offer the highest quality renal replacement therapy to our patients. These patients are not only concerned about their deteriorating health, but also do not want to burden their loved ones. Home modalities have been shown to be able to provide patients and their families the independence that comes with being responsible for their own healthcare. Lastly it will help to reinvigorate the relationship between the nephrologist and CKD patient. I believe that if the nephrology community makes this its primary focus over the next decade we can work together with a common goal to make our specialty one that emphasizes quality and compassionate care and is attractive to incoming classes of medical specialists.
- Singh, A: The nephrology workforce crisis. Neph Times 2015 Jan-Feb 7(1):4
- Jain AK, Blake P, Cordy P, Garg AX: Global trends in rates of peritoneal dialysis. J Am Soc Nephrol. 2012;23 (3):533
3.. Paraskevi, T: Quality of life in patients undergoing hemodialysis or peritoneal dialysis treatment. J Clin Med Res. 2011 Jun3 (3): 132-138