Marcello Tonelli, MD, SM, MSc speaks about the complexities of treating nephrology patients in recent study

By Marcello Tonelli, MD, SM, MSc

tonelli.jpgA recent study was published online in the Journal of the American Medical Association (JAMA) entitled “Comparison of the Complexity of Patients Seen by Different Medical Subspecialists in a Universal Health Care System” on November 30, 2018.

Please access the abstract and full report on the JAMA website.

To get a behind-the-scenes look into the study, Kidney News Online asked ASN Member, Marcello Tonelli, MD, SM, MSc, lead author and Associate Vice President (Research) at the University of Calgary Cumming School of Medicine, to answer several questions about the findings and what they mean for the future.

1. How would you briefly describe the findings of this study?

We first did a literature review summarizing what is known about how to measure the complexity of a given patient, and selected nine markers that had face validity and could be assessed using administrative health data. We then assembled a cohort of 2.5 million Canadian adults treated in a Universal Health system, and characterized each individual in terms of the nine complexity markers. Finally, we assessed the specialty of any physician who saw each patient during a one-year period, allowing us to assess the complexity of the average patient seen by each specialty. Importantly, only certain medical specialties were included in the study.

First, we found substantial differences in the distribution of these quality markers between different specialties. Second, there were consistent patterns in these differences between specialties. For example, patients seen by nephrologists, infectious disease specialists, and neurologists consistently appeared to be more complex, whereas patients seen by allergists, dermatologists, and family physicians consistently appeared to be less complex.

2. What do you believe is the importance of the findings?

Although of course nephrologists are interested in the finding that our patients are among the more complex, we believe it is more important and interesting to document that these between-specialties exist rather than to focus on the ranking itself. Many health systems don't explicitly address complexity when allocating resources or structuring services; complexity per se is not featured in all medical school or residency curricula; and better management of complex patients is not always clearly incentivized by current models of care. Most importantly, our study opens the door to other measures of complexity, including opiate use, languages barriers, poor health literacy, sensory impairment and limited social networks.

3. What effect do you think your team’s proof of these findings will have on the future of treating patients?

We hope that it will help to open a discussion about how to better manage complexity, and to help inform the necessary adjustments to health policy, models of care and medical education.

4. Going forward, do you think the findings will influence medical school students when choosing a specialty?

I think all practicing nephrologists will agree that it is necessary to be comfortable with medical and social complexity in order to provide good care to kidney patients. Having said that, I don't think that average complexity should be a major factor when choosing a specialty, but it certainly is one factor that could be considered and our study does provide some information on that.

5. Have you found any elevated personal burnout in specialties with more complexity?

We speculate that complexity is one factor that might contribute to burnout -- and the interaction between complexity and other factors such as EMRs is particularly interesting. This might be a topic for future study, since we did not have any information on burnout per se. However, since complexity is inherent to many specialties (including nephrology), we think that the focus should be on effective and efficient management of medical and social complexity – which hopefully will reduce the risk of physician burnout while also improving outcomes for the patients we serve.

jonathan-himmelfarb.jpgPast ASN president (2014-2015), director of the University of Washington’s Kidney Research Institute, and co-author on the study, Jonathan Himmelfarb, MD, also weighed in on the findings of this interesting study:

“It will not come as a surprise to most nephrologists (and I suspect the same is true for infectious disease physicians and neurologists) that their patient encounters are associated with considerable medical complexity. Many nephrologists, myself included, were attracted to our sub-specialty because of the complexity in understanding how the kidney functions in health and disease.

Moreover, when the kidney cannot fully filter the blood of toxins and maintain circulatory homeostasis, multiple other organs systems are simultaneously affected, creating a myriad of complex signs and symptoms. While perhaps not surprising, the findings in the paper should be helpful, particularly from a health policy standpoint.”

If you have any further questions on this study or the broader topic, please contact Kidney News Online at info@kidneynews.org.

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Author:
Marcello Tonelli, MD, SM, MSc
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tonelli.jpgA recent study was published online in the Journal of the American Medical Association (JAMA) entitled “Comparison of the Complexity of Patients Seen by Different Medical Subspecialists in a Universal Health Care System” on November 30, 2018.

Please access the abstract and full report on the JAMA website.

To get a behind-the-scenes look into the study, Kidney News Online asked ASN Member, Marcello Tonelli, MD, SM, MSc, lead author and Associate Vice President (Research) at the University of Calgary Cumming School of Medicine, to answer several questions about the findings and what they mean for the future.

1. How would you briefly describe the findings of this study?

We first did a literature review summarizing what is known about how to measure the complexity of a given patient, and selected nine markers that had face validity and could be assessed using administrative health data. We then assembled a cohort of 2.5 million Canadian adults treated in a Universal Health system, and characterized each individual in terms of the nine complexity markers. Finally, we assessed the specialty of any physician who saw each patient during a one-year period, allowing us to assess the complexity of the average patient seen by each specialty. Importantly, only certain medical specialties were included in the study.

First, we found substantial differences in the distribution of these quality markers between different specialties. Second, there were consistent patterns in these differences between specialties. For example, patients seen by nephrologists, infectious disease specialists, and neurologists consistently appeared to be more complex, whereas patients seen by allergists, dermatologists, and family physicians consistently appeared to be less complex.

2. What do you believe is the importance of the findings?

Although of course nephrologists are interested in the finding that our patients are among the more complex, we believe it is more important and interesting to document that these between-specialties exist rather than to focus on the ranking itself. Many health systems don't explicitly address complexity when allocating resources or structuring services; complexity per se is not featured in all medical school or residency curricula; and better management of complex patients is not always clearly incentivized by current models of care. Most importantly, our study opens the door to other measures of complexity, including opiate use, languages barriers, poor health literacy, sensory impairment and limited social networks.

3. What effect do you think your team’s proof of these findings will have on the future of treating patients?

We hope that it will help to open a discussion about how to better manage complexity, and to help inform the necessary adjustments to health policy, models of care and medical education.

4. Going forward, do you think the findings will influence medical school students when choosing a specialty?

I think all practicing nephrologists will agree that it is necessary to be comfortable with medical and social complexity in order to provide good care to kidney patients. Having said that, I don't think that average complexity should be a major factor when choosing a specialty, but it certainly is one factor that could be considered and our study does provide some information on that.

5. Have you found any elevated personal burnout in specialties with more complexity?

We speculate that complexity is one factor that might contribute to burnout -- and the interaction between complexity and other factors such as EMRs is particularly interesting. This might be a topic for future study, since we did not have any information on burnout per se. However, since complexity is inherent to many specialties (including nephrology), we think that the focus should be on effective and efficient management of medical and social complexity – which hopefully will reduce the risk of physician burnout while also improving outcomes for the patients we serve.

jonathan-himmelfarb.jpgPast ASN president (2014-2015), director of the University of Washington’s Kidney Research Institute, and co-author on the study, Jonathan Himmelfarb, MD, also weighed in on the findings of this interesting study:

“It will not come as a surprise to most nephrologists (and I suspect the same is true for infectious disease physicians and neurologists) that their patient encounters are associated with considerable medical complexity. Many nephrologists, myself included, were attracted to our sub-specialty because of the complexity in understanding how the kidney functions in health and disease.

Moreover, when the kidney cannot fully filter the blood of toxins and maintain circulatory homeostasis, multiple other organs systems are simultaneously affected, creating a myriad of complex signs and symptoms. While perhaps not surprising, the findings in the paper should be helpful, particularly from a health policy standpoint.”

If you have any further questions on this study or the broader topic, please contact Kidney News Online at info@kidneynews.org.

Date:
Monday, December 17, 2018