ESRD Seamless Care Organizations (ESCOs) may be the most flexible and innovative care model in nephrology over the past several decades. Tom Duvall, co-lead for the Comprehensive ESRD Care (CEC) Model at the Center for Medicare and Medicaid Innovation (CMMI), provided a national overview of ESCOs since their start in 2015. Dr. Dylan Steer, CEO of Balboa Nephrology Medical Group, then shared his ground-level experience with running an ESCO.
“I wish he had a better death, but more than that, I wish he had a better life.”
This is the sentiment of a provider describing the life and death of an undocumented patient suffering from end-stage renal disease in the United States, as relayed by Dr. Rajeev Raghavan, MD, FASN and Associate Professor of Medicine/Nephrology at Baylor College of Medicine. Dr. Raghavan spoke to us about the difficulties in delivering nephrology care for the undocumented, particularly with the forced reliance on Emergency-only dialysis. Emergency-only dialysis is variable among location, but the unfortunate reality is that dialysis patients present to the emergency room and dialyzed on an emergency only basis, and if they are discharged without dialysis, there is a chance that their next visit they may be “crashing” right into dialysis. We are very much aware that emergency-only dialysis is associated with nearly a 9x higher hazard ratio of death and a considerably much higher cost with an estimate of $284,000 as compared to a cost of ~$60,000 for chronic dialysis, yet policy measures still only allow for this unfavorable approach in terms of medical, holistic, cost effectiveness and ethical care.
Long-term survival among black and Hispanic children after kidney transplant worsened compared with their white counterparts over the past 2 decades, found a study presented at Kidney Week 2018.
Improvements in surgical techniques and immunosuppression strategies have led to substantial improvements in the outcomes for child kidney transplants overall. But whether those improvements have helped close racial and ethnic disparities in child kidney transplant outcomes documented in the 1980s and 1990s was unclear, said Tanjala Purnell, MPH, PhD, assistant professor of surgery in the division of transplantation at Johns Hopkins University School of Medicine in Baltimore. A 2016 study of adult transplant recipients found improvements in outcomes for both white and black transplant recipients over the past 20 years.
In today’s session on the “Future of Value-Based Care,” Tom Duvall, co-lead on the ESRD Seamless Care Organization (ESCO) models at the CMS Innovation Center, updated Kidney Week attendees on the status of the ongoing ESCO models that qualify as Advanced Alternative Payment Models (APMs) under the Quality Payment Program. Duvall asked for feedback on how the models are currently operating and for input on how to accomplish various goals as CMS considers the next iteration of ESCOs after the current ones are completed in 2020. In particular, Duvall requested Kidney Week participants submit answers to four questions:
More conservative use of blood transfusions during cardiac surgery is safe for the kidneys, suggests results from the Transfusion Requirements in Cardiac Surgery-III (TRICS-III) trial presented at Kidney Week 2018 in San Diego, CA.
The 20 million cardiac surgeries done worldwide each year consume about 20% of the world’s blood supply, said Amit Garg, MD, PHD, nephrologist at the London Health Sciences Center in Ontario, Canada. Blood transfusions are often used during such surgeries to prevent hypoxia caused by low blood supply to the organs, particularly the kidneys, which are easily injured by low blood flow. But blood transfusions themselves can also cause kidney injury as well as other adverse effects. Safely reducing the number of transfusions needed for such surgeries would not only help conserve the blood supply and reduce health care costs, but also reduce adverse effects of the blood transfusion itself, he said. As a result, the National Institutes of Health Heart Lung and Blood Institute has made funding randomized trials of red cell blood cell transfusions a priority.
Following an aspirational policy-oriented kick-off at Kidney Week, I found that the second day of Kidney Week focused on the most important aspect of what we do: our patients. From the public-private partnerships including KidneyX and Kidney Health Initiative (KHI), to the CMS proposed payment changes, to the global challenges facing nephrology, the common sentiment has been simple: we must not forget our efforts to keep the patient at the center and include patient participation and insight.
Quality of care measurement and implementation both pose unique challenges. The Friday morning session at ASN Kidney Week, “Quality is Job One: Improving Care for CKD and ESRD Patients” tackled these two key issues.
Nephrology has seen a proliferation of quality metrics, primarily in its ESRD Quality Incentive Program (QIP). Daniel E. Weiner, MD, FASN, chair of ASN’s Quality Committee, shared his framework for assessing quality metrics, based on his experience developing these in conjunction with the Centers for Medicare and Medicaid Services (CMS).
“A new app to help individuals with kidney disease track daily eating habits, daily activities, medications and efforts to self-manage their disease is being tested”.
With development lead by the US Department of Veterans Affairs, the American Association of Kidney Patients, and the American Society of Nephrology, the app is in “beta phase testing” but will eventually be released to veterans, as well as the general public.
This past week, I had the privilege of attending a panel discussion on health in the African American community hosted by my local church. Black community health professionals shared insightful advice, promoting health-seeking behavior in communities of color. Yet, when it was time for audience questions, the program took an unexpected turn: person after person lined up to share stories of mistreatment and disregard at the hands of medical professionals. It was painful to hear how little my community trusted health professionals like me to be a part of their healing.