Here’s another update from the Boston conference, posted by Gary Peterson on Renalweb (http://renalweb.groupee.net/eve/forums/a/tpc/f/5911014023/m/148103735
March 18, 2010 - An important, remarkable, and memorable Renal Physicians Association (RPA) Annual Meeting was held March 12-15 in Baltimore. The most provocative presentation was given again this year by Dr. Tom Parker, who provided an update on the 2009 Boston ESRD conference and the interactions of its steering committee with officials at the Centers for Medicare and Medicaid Services (CMS). An indication of how much impact the Boston conference has had was evident by the presence and participation of CMS’s chief medical officer, Dr. Barry Straube, at the American Association of Kidney Patients’ dinner on March 13th that honored Dr. Parker. Remarkably, these two men did not know each other a year ago. Dr. Straube also spoke to the RPA conference attendees on March 15th.
In summarizing the Boston ESRD conference and the consensus thinking that has followed, Dr. Parker called for the end of many of the foundations of end-stage renal disease (ESRD) medical care for the last 20-30 years:
– Stop emphasizing Kt/V (and its derivative URR) as a measure of dialysis adequacy. It is not enough. It does not work for small patients and does not deliver euvolemia (normal blood volume and associated blood pressures). All the work done on improving the measurement of “dialysis dose” has not improved outcomes.
– End dry weights. Dry weight is an “evil doer.” Euvolemia must become a primary measure of dialysis adequacy. Hypervolemia is the leading cause of hospitalizations and deaths. Evidence appears to be building of the potential harm of sodium modeling.
– Almost no one should dialyze less than four hours. Time and euvolemia must become new clinical performance measures. Cardiac stunning is freqently seen with the high ultrafiltration rates associated with short-time dialysis treatments. A Technical Expert Panel (TEP) held earlier in the week at CMS addressed these issues and will announce recommendations later.
– End the renal diet, with the exception of sodium restrictions (and extreme potassium sources). The renal diet has functioned to produce satisfactory biochemical markers (good lab work), but has resulted in malnourished patients. Current clinical performance measures (Kt/V, Ca, P, etc.) only explain 14% of the differences in mortality seen between facilities.
– Hemodialysis catheters are iatrogenic (harm caused by physicians). Vascular access infections are a major cause of first year mortality. Catheters are also a leading cause of sepsis, inflammation, complications, and hospitalizations. Instead of thinking “Fistula First,” we should emphasize “Catheter LAST.” Patients who have catheters have overall care costs that average at least $20,000 more per year than patients who have fistulas.
–Emphasis must be placed on incident (new) patients. 70% of patients die in the first five years. Recent statistics show that up to 40% of patients die in the first year.
– Statins don’t work to reduce mortality. ESRD patients aren’t dying of ASCVD.
– ESAs haven’t worked to reduce mortality.
It was frustrating that Dr. Parker could still not comment on changes that are being considered by CMS for implementation. However, judging by Dr. Straube’s comment that he now considers dialysis adequacy to be a composite of measures, changes appear to be coming.
Dr. Allen Nissenson gave further hints about the long-awaited work by Dr. Brennan Spiegal and his UCLA colleagues. They found that you can take two facilities with the same case mix, Kt/V, time on dialysis, albumin levels, etc – all the usual biochemical and treatment measurements – and the outcomes can still vary as much as 39%. In the past, it was reported that they were looking at over 150 variables such as personnel issues, communication patterns, patient education, facility environment, staff morale, etc. to explain these differences. Dr. Nissenson “leaked” that they have identified five variables that are associated with a 31% variance in mortality between similar CPM-performing facilities:
– Dietitians tailoring food plans for cultural considerations
– Rapidity of patient care conferences after patient hospitalization
– Perceived quality of continuing medical education (CME)
– Willingness of patients to learn about self-care
– Patient discipline in following medical advice
Dr. Straube from CMS was the next-to-last speaker at the conference. He is both the chief medical officer and the Director of the Office of Clinical Standards and Quality at CMS. He is also a nephrologist.
Dr. Straube first emphasized that the HHS/CMS data is a national asset and will be more available to researchers. As a starting point, he suggested visiting www.data.gov.
– He called for a resurgence in patient-centered care in ESRD, citing a need for:
Increased informed and collaborative decision-making
– Ending racial, geographic, economic, gender-based, and condition-related disparities in care
– Increased attention to functional status and the patient experience
– Improving management of difficult patients
– Increased focus on palliative and end-of-life care
– Defining patient responsibilities
Dr. Straube also said more attention would be paid to these clinical issues:
– Cardiovascular – volume, fluid, salt
– Vascular access – fewer catheters and infections
– Anemia management – ESAs, ESA resistance, iron management
– Adequacy – What are the correct measures? Is adequacy a composite?
– Mineral metabolism – What are the ideal measures?
– Linking CKD and ESRD care across the continuum
– Determining the best modalities for subgroups of ESRD patients
When he took questions at the end of his presentation, a question led Dr. Straube to comment that, “We should be outraged by (patient) cherrypicking. It is our responsibility to do something. It’s immoral.”
Editor’s note (from Gary Peterson): As it becomes more evident that our high-tech, corporate-based approach to ESRD care for the last twenty years has not delivered the best or appropriate care for patients - and considering Dr. Straube’s call for a resurgence in patient-centered care - I believe it is time to redefine care in terms of patient life experiences. It was never the intent of the federal ESRD program to create hundreds of thousands of disabled and debilitated patients, as our system does today.
This reform movement has been led by corporate outsiders. Can we trust the major corporations to do the right thing for patients? Knowing that we have been going down the wrong paths for so long, what will be seen as the legacy of the current corporate leadership of FMC, DaVita, and Amgen?
This message has been edited. Last edited by: Gary Peterson, 19 March 2010 04:23 AM