The chronic kidney disease epidemic: a challenge for nephrology training programs

Renal Dialysis and its Financing

The incidence of end-stage renal disease (ESRD) and its associated comorbidities such as diabetes and hypertension continue to increase as the population ages. As most ESRD patients qualify for Medicare coverage, the U.S. government initiated reforms of the payment system for dialysis facilities in an effort to decrease expenditures associated with ESRD reimbursement. The effects of reduced reimbursement rates, bundled payment options, and quality incentives on the current dialysis system, including kidney dialysis units, physicians, and patients, are examined.

The global nephrology workforce: emerging threats and potential solutions!

Amidst the rising tide of chronic kidney disease (CKD) burden, the global nephrology workforce has failed to expand in order to meet the growing healthcare needs of this vulnerable patient population. In truth, this shortage of nephrologists is seen in many parts of the world, including North America, Europe, Australia, New Zealand, Asia and the African continent. Moreover, expert groups on workforce planning as well as national and international professional organizations predict further reductions in the nephrology workforce over the next decade, with potentially serious implications. Although the full impact of this has not been clearly articulated, what is clear is that the delivery of care to patients with CKD may be threatened in many parts of the world unless effective country-specific workforce strategies are put in place and implemented. Multiple factors are responsible for this apparent shortage in the nephrology workforce and the underpinning reasons may vary across health systems and countries. Potential contributors include the increasing burden of CKD, aging workforce, declining interest in nephrology among trainees, lack of exposure to nephrology among students and residents, rising cost of medical education and specialist training, increasing cultural and ethnic disparities between patients and care providers, increasing reliance on foreign medical graduates, inflexible work schedules, erosion of nephrology practice scope by other specialists, inadequate training, reduced focus on scholarship and research funds, increased demand to meet quality of care standards and the development of new care delivery models. It is apparent from this list that the solution is not simple and that a comprehensive evaluation is required. Consequently, there is an urgent need for all countries to develop a policy framework for the provision of kidney disease services within their health systems, a framework that is based on accurate projections of disease burden, a full understanding of the internal care delivery systems and a framework that is underpinned by robust health intelligence on current and expected workforce numbers required to support the delivery of kidney disease care. Given the expected increases in global disease burden and the equally important increase in many established kidney disease risk factors such as diabetes and hypertension, the organization of delivery and sustainability of kidney disease care should be enshrined in governmental policy and legislation. Effective nephrology workforce planning should be comprehensive and detailed, taking into consideration the structure and organization of the health system, existing care delivery models, nephrology workforce practices and the size, quality and success of internal nephrology training programmes. Effective training programmes at the undergraduate and postgraduate levels, adoption of novel recruitment strategies, flexible workforce practices, greater ownership of the traditional nephrology landscape and enhanced opportunities for research should be part of the implementation process. Given that many of the factors that impact on workforce capacity are generic across countries, cooperation at an international level would be desirable to strengthen efforts in workforce planning and ensure sustainable models of healthcare delivery.

Nephrology care prior to end-stage renal disease and outcomes among new ESRD patients in the USA

Background

Longer nephrology care before end-stage renal disease (ESRD) has been linked with better outcomes.

Methods

We investigated whether longer pre-end-stage renal disease (ESRD) nephrology care was associated with lower mortality at both the patient and state levels among 443 761 incident ESRD patients identified in the USA between 2006 and 2010.

Results

Overall, 33% of new ESRD patients had received no prior nephrology care, while 28% had received care for >12 months. At the patient level, predictors of >12 months of nephrology care included having health insurance, white race, younger age, diabetes, hypertension and US region. Longer pre-ESRD nephrology care was associated with lower first-year mortality (adjusted hazard ratio = 0.58 for >12 months versus no care; 95% confidence interval 0.57–0.59), higher albumin and hemoglobin, choice of peritoneal dialysis and native fistula and discussion of transplantation options. Living in a state with a 10% higher proportion of patients receiving >12 months of pre-ESRD care was associated with a 9.3% lower relative mortality rate, standardized for case mix (R² = 0.47; P < 0.001).

Conclusions

This study represents the largest cohort of incident ESRD patients to date. Although we did not follow patients before ESRD onset, our findings, both at the individual patient and state levels, reflect the importance of early nephrology care among those with chronic kidney disease.

State level variations in nephrology workforce and timing and incidence of dialysis in the United States among children and adults: a retrospective cohort study

BACKGROUND

Multiple factors influence timing of dialysis initiation. The impact of supply of nephrology workforce on timing and incidence of dialysis initiation is not well known.

METHODS

We determined the number of pediatric and adult nephrologists in each state using data from the American Medical Association and American Boards of Internal Medicine and Pediatrics. We ascertained state population data from the 2010 US Census. United States Renal Data System (USRDS) data were used to determine estimated glomerular filtration rate (eGFR) at dialysis initiation and dialysis incidence for adults (≥18 years) in 2008 and children (<18 years) in 2007-2009 by state.

RESULTS

Across all states, there were a median of 3.0 (IQR 2.3 to 3.4) adult nephrologists per 100,000 adults and 0.5 (IQR 0.2 to 0.9) pediatric nephrologists per 100,000 children. The median eGFR at start of dialysis was 9.8 mL/min/1.73 m2 (IQR 7.1-13.1) in adults and 8.5 mL/min/1.73 m2 (IQR 6.2-11.4) in children. Neither the number of adult (Spearman r of 0.02 [95% CI -0.26-0.30], p = 0.88) nor pediatric (Spearman r of -0.13 [95% -0.39-0.15], p = 0.38) nephrologists per state population was associated with mean eGFR across states. The number of nephrologists per state population was associated with incident dialysis cases per state population in adults (Spearman r of 0.50 [95% CI 0.26-0.68], p = 0.0002), but not in children (Spearman r of -0.06 [95% CI -0.33-0.22], p = 0.67). In linear regression models, the association between nephrologists per state population and incident dialysis cases per state population remained statistically significant (p = 0.006) after adjustment for provider characteristics.

CONCLUSIONS

Nephrology workforce supply is aligned with demand but does not appear to be associated with timing of dialysis initiation.

Training the next generation's nephrology workforce

The subspecialty of nephrology faces several critical challenges, including declining interest among medical students and internal medicine residents and worrisome declines in the number of applicants for nephrology fellowships. There is an urgent need to more clearly define the subspecialty and its scope of practice, reinvigorate meaningful research training and activities among trainees, and ensure that fellows who complete training and enter the practice of nephrology are experts in the broad scope of nephrology. This need requires a critical look at fellowship training programs and training requirements. A new workforce analysis is also needed that is not focused on primarily meeting estimated future clinical needs but rather, ensuring that there is alignment of supply and demand for nephrology trainees, which will ensure that those entering nephrology fellowships are highly qualified and capable of becoming outstanding nephrologists and that there are desirable employment opportunities for them when they complete their training.

Comanagement of diabetic kidney disease by the primary care provider and nephrologist

DKD is a complex and multifaceted disease. A substantial portion of patients remain unable to attain clinical targets for glycosylated hemoglobin, lipids, and blood pressure. Improving outcomes requires multifactorial interventions that are best delivered through collaborative care. Targets for improvement should include screening, diagnosis, and early referral. Following referral, the patient should be cared for in an integrated framework using the 4 elements of an effective DKD care delivery model: clear roles and responsibilities, integrated QI programs, MDT approach, and effective communication facilitated through access to a shared EMR. Given the differences in the pathophysiology of DM in the renal population, a nephrologist and endocrinologist can be invaluable in improving care for this population. Large-scale trials are needed to validate the cost and usefulness of collaborative care as current data are insufficient. Based on available data, models such as the one proposed here should serve to maximize the strengths of individual providers and provide improved quality of care to patients.

The role of primary care in the management of the chronic kidney disease population

With the recognition of the high prevalence of CKD and its associated morbidity and mortality, increasing attention has focused on how to optimally provide care to this population. An immediate concern is that the sheer size of the population with early-stage CKD will overwhelm the capacity of the current nephrology workforce. Thus, the burden of care for most CKD patients will likely have to fall on primary care physicians (PCPs). This article reviews the issues surrounding the role of primary care in the management of the CKD population. Topics covered include specific roles that PCPs can play in the care of CKD patients, barriers and challenges to PCP involvement, and a discussion of strategies to improve the care provided to CKD patients by PCPs.