Download - IQ:CKD Spring 2009
There’s a sort of Zen-like quality about
Dr. Eric Gardner as he discusses what he
does for a living and why he does it.
Having renounced the glamour of per-
forming cardiovascular surgery, he now
spends three days a week performing a sur-
gery that makes life more bearable for pa-
tients needing dialysis. He is a vascular
surgeon who specializes in performing arte-
riovenous fistula (AVF) placement.
In 2007 Gardner moved his Collierville,
Tenn., practice’s focus to be strictly on pa-
tients needing vascular surgery, primarily
AVFs. “When you focus on one niche, you
end up getting very good at it,” he said.
“I saw a need where dialysis patients
were getting upset, because most of the sur-
geons performing dialysis access surgery typ-
ically had more pressing operations that took
priority, often resulting in long patient wait
times for appointments and ultimately sur-
gery,” he said. “The Mid-South has a tremen-
dous population of dialysis patients with
untreated hypertension and the gamut of
renal disease. No one really focused on these
patients in giving them the attention and serv-
ice that they deserve.”
Patient EducationMost patients who arrive at Gardner’s of-
fice know why they are there. Their nephrol-
ogist has prepped and educated them on the
need for dialysis. Once there, Gardner dis-
cusses access options and preliminary steps
that need to be taken.
“A fistula is always the first goal,” he
said, when it comes to discussing access op-
tions with patients.
He reviews the various placement op-
tions for a fistula, but prefers to place a fistula
as far from the heart as possible. He explains
to patients that an access further away from
the heart (such as at the wrist) prolongs lives
by saving the bigger veins and allows for
more “real-estate” for future access needs.
Gardner typically sees 30 patients a day,
twice a week and spends the remainder of the
week doing surgery. Of those 30 patients, 8
to 12 are new patients. Most of these patients
are going into surgery for fistula placement.
Fistula creation usually takes Gardner an
average of 30 minutes and is an outpatient
procedure. “I usually tell my patients they
can resume their normal activities later that
day,” he said, with an average total time of 4
to 8 hours including surgery and recovery.
One of the hardest parts of what he does
is getting patients to understand and accept
what is happening and overcome their fear.
It is also one of the best parts. He usually
does a comparative analysis of a patient with-
out a fistula and another patient with a fistula.
“Patients who receive their first dialysis
treatment with a fistula live longer, have a
better quality of life, have fewer hospital vis-
its, fewer infections and less costs,” he said.
“That usually convinces them. That and the
fact that fistula placement is usually a simple
procedure to recover from quickly.”
Fistulas are preferred to catheters, he
said. Catheters extend outside the body, lead
to infection and need replacement.
“Having a catheter or graft is less desir-
able than having a fistula,” he said, in regards
to fistulas being considered the “gold stan-
dard” for vascular access. “I’m able to do the
complete range of dialysis access procedures,
but knowing how important access strategy
is for a dialysis patient, I try to exhaust all
possibilities for a fistula before I put in a
catheter or graft. It’s a quality of life factor.
The patient with a fistula typically has fewer
complications and dialysis is more effective
and efficient.”
Draw a MapThe biggest challenge he and most vas-
cular surgeons face is locating a suitable site
for fistula placement as many patients who
make their way to his office have often had
2 IQ:CKD Spring 2009
multiple vein punctures. Nephrologists are
good about identifying patients that may
need dialysis and educating patients on sav-
ing their arms and/or veins. The non-domi-
nant arm is usually the one chosen for
fistula access.
“Many elderly patients or those that
have (vascular) trauma from multiple punc-
tures for IVs and blood draws typically will
have scarred or nonexistent veins, making
it that much more difficult to create dialysis
access and have a fistula,” he said.
The key to Gardner’s success is having
an ultrasound unit in the exam room with
the patient. He is able to examine the pa-
tients’ veins and arteries to make sure they
are suitable for a fistula and to identify any
kind of abnormalities that may exist preop-
eratively that might otherwise have resulted
in postoperative failure.
“I’m looking for scarred veins, veins
that are too small or areas of the vein that
won’t dilate,” he said.
Gardner says he draws pictures to
“map” his operation out, so he knows what
he is doing for a particular patient. Fistula
failures have occurred because surgeons did
not do vein-mapping or use ultrasound to
determine vein integrity. Nationally, the
failure rate of fistulas has decreased.
Many of his patients have been told by
other physicians that they have exhausted
all options for vascular access. However,
there have been very few patients he has
had to turn away because of a lack of viable
choices.
“Having preoperative studies and ultra-
sounds has raised my rate of success
tremendously,” he said. “The fact that I’m
doing it myself is so much more valuable.”
The Challenging PartWhat could prove even more valuable
to the success of an AVF is identifying pa-
tients in the early stages of CKD.
Many of his patients have been referred
beyond the time needed to appropriately
allow for fistula placement because many
of these patients were not aware that their
kidneys were failing prior to their need for
dialysis.
However, the trend is changing thanks
to the Fistula First Initiative and the Kidney
Disease Outcomes Quality Initiative
(KDOQI) Guidelines. The Guidelines di-
rect physicians on providing appropriate
care for all stages of CKD, related compli-
cations and dialysis. Gardner said he is now
seeing more patients earlier with Stage 3
and Stage 4 CKD instead of receiving them
at the final stage (Stage 5).
Early detection and prevention is the
key to a patient’s care, especially if the pa-
tients are on a path to eventually see him.
“I mostly get referrals from nephrolo-
gists,” he said. “But I would like to see
PCPs (primary care physicians) refer pa-
tients as well.”
According to Gardner, one main reason
PCPs aren’t making referrals is that they
may not know what to look for in terms of
renal function. When a CKD patient’s cre-
atinine clearance is 15 to 30 percent, the pa-
tient needs to be referred to a surgeon as
this signifies that patients have entered
Stage 3 and Stage 4 of the disease.
Gardner encourages physicians to take
preventative steps by monitoring the con-
ditions that can lead to CKD — such as di-
abetes and hypertension. Patient education
is necessary in the early stages.
Not About MoneyWhile a fistula may be the “gold stan-
dard” for dialysis access, it hasn’t been a
gold mine for physicians.
Historically, those surgeons who have
placed fistulas have made less, because
Medicare paid less for them even though
they are harder to perform and work better,
Gardner said.
Reimbursement for fistulas is not as
much as a graft or a catheter. The downside
is that complications resulting from grafts
and catheters can lead to more procedures
to correct new problems.
However, Medicare has recently in-
creased reimbursement of fistula placement
by 30 percent which may result in an in-
crease of surgeons who perform the proce-
dure.
“I’m much happier doing the right
thing for the patient and not compromising
my beliefs that fistulas are the right thing
to do,” he said. “It’s not the glamorous sur-
gery, but my workday is done by 3 p.m., I
spend more time with my family and I have
healthy and happy patients.”
IQ:CKD Spring 2009 3
An apple a day for chronic kidney disease (CKD)
patients could have more benefit than Benjamin
Franklin first supected when he wrote the saying in
the Poor Richard’s Almanac.
Good nutrition is essential to a CKD patient’s
overall health and chomping on an apple (or other
healthy food) can make all the difference when
preparing for a fistula and after its placement.
Early Placement Early fistula placement can have a major impact
on nutritional outcomes in the early stages of dialy-
sis for several reasons, as malnutrition is a major
factor contributing to morbidity and mortality
among CKD patients.
The proportion of CKD patients that have protein
energy malnutrition is substantial. Several studies
have documented that 20 to 60 percent of patients
on hemodialysis are malnourished, especially in the
first 90 days of treatment. Malnourished patients
suffering from a lack of appetite, a manifestation of
uremia, initiate dialysis with a higher risk of hospi-
talization and mortality.
Dialysis AdequacyPatients with mature fistulas at the initiation of
dialysis will achieve better Kt/V results. According
to the National Kidney Foundation’s Kidney Dialy-
sis Outcomes Qualitity Initiative (KDOQI) Guide-
lines, Kt/V is a number used to quantify
hemodialysis and peritoneal dialysis treatment ade-
quacy. In medical equations, K is dialyzer clearance
of urea, t is dialysis time and V is the patient’s total
body water.
Normalized protein catabolic rate (nPCR) is a
parameter that has been widely used as a marker of
protein intake. Research has shown that protein cata-
bolic rates increase linearly with the Kt/V indicating
4 IQ:CKD Spring 2009
patients are more adequately nour-
ished when they are well dialyzed.
The improvement in nutritional
status is likely indicative of an in-
crease in protein intake as a result
of an improved appetite because
the patient’s blood is more thor-
oughly cleaned.
Counseling the patient to in-
crease dietary protein intake will be
ineffective if the patient is receiv-
ing poor dialysis.
It is imperative that a patient
gets a good start with a fistula to
achieve dialysis adequacy, but also
to help fight infection and inflam-
mation.
Inflammation suppresses ap-
petite, increases muscle catabolism,
and can result in progressive
cachexia. Infection and nutritional
status have been shown to be inde-
pendent predictors of hypoalbu-
minemia in dialysis patients.
Infection RateInfection creates a downward
spiraling cycle that affects the nu-
tritional status of the kidney pa-
tient. The increased risk of
infection with catheters will lower
albumin levels in CKD patients and
places them at risk for malnutrition.
In turn, low albumin levels
make it difficult for patients to
fight infection.
For patients initiating dialysis,
a mature fistula affects the infec-
tion/nutrition cycle in a positive
way, due to a lower rate of infec-
tion and improved appetite through
adequate dialysis.
Serum albumin levels are used
extensively to assess the nutritional
status of CKD patients. One of the
most powerful predictors of sur-
vival in the first 90 days of dialysis
treatment is an albumin level of
less than 30 g/l.
This makes hypoalbuminemia
highly predictive of future mortal-
ity risk, both at initiation and
throughout the course of mainte-
nance dialysis.
Best PracticesGetting patients involved in the
maintenance of their health at the
earliest stage possible is very im-
portant. Patients should be encour-
aged to attend annual Kidney Early
Evaluation Program (KEEP)
screenings, CKD options classes
provided by most dialysis compa-
nies and health fairs.
In order for patients to achieve
early fistula placement, early refer-
ral is essential. Primary care physi-
cians should refer their patients to
a nephrologist early upon diagno-
sis. This will allow for vein map-
ping and identifying patients who
are candidates for fistula place-
ment.
Patients are also recommended
to receive nutritional education by
a renal dietician. Dieticians can
help manage comorbidities con-
tributing to kidney failure such as
diabetes and hypertension and en-
sure appropriate intake of calories
and protein to maintain a healthy
weight and prevent malnutrition.
Dieticians can also provide ed-
ucation on sources and optimal in-
take of antioxidants to decrease
inflammation, as well as on chang-
ing sodium, potassium, phosphorus
and fluid needs as the patient pro-
gresses through the stages of CKD.
IQ:CKD Spring 2009 5
Nephrologist Dr. Vo Nguyen got his wake-up call about
vascular access in 1996.
Actually, it was a triple wake-up call, according to
Nguyen, medical director of Aberdeen Dialysis Center, Renal
Care Group of the Northwest, Olympia, Wash., and member
of the American Society of Diagnostic and Interventional
Nephrology.
His dialysis group got a warning letter from the Medical
Review Company about a high rate of hemodialysis arteri-
ovenous (AV) graft failure among end stage renal disease pa-
tients on chronic hemodialysis.
Then vascular surgeon partners balked at the need to in-
tervene when AV grafts thrombosed — sometimes at mid-
night after all the day’s scheduled operations were
completed. And he was shaken by the generally poor patient
outcomes from dialysis catheters and grafts, which are more
prone to severe infection.
Nguyen, who had always considered AV access as the
concern of the surgeon rather than the nephrologist, went to
surgeon Chris Griffith and asked for help. Working with
Griffith and other members of the dialysis team, they created
a program to shift from grafts to fistula as the standard AV
access — an unusual strategy, compared to the standard of
practice in the United States.
Why AV Fistula?Like most nephrologists, Nguyen did not have formal
training in AV fistula creation and had gone with AV grafts
as the default because they are simpler and quicker to create
than fistulae. To create an AV fistula, a surgeon needs a well-
mapped target for joining an artery and a vein, and it typi-
cally takes weeks or months for the fistula to mature before
use.
"Who wants to spend six months waiting?" says Nguyen.
Studies show, however, that AV fistula achieve a higher
survival rate than AV grafts, with less thrombosis and infec-
tion. Nguyen also knew that most European dialysis patients
receive fistula.
Making the transition became a "true passion" for
Nguyen, as he describes it. Griffith helped him understand
the vascular surgeon’s information needs and operating pro-
cedures. Nguyen also read extensively about AV access and
talked with European nephrologists during several visits
there and online with Renaliste, an email distribution list for
Francophone nephrologists. Key nursing staff volunteered
to learn the sometimes forgotten art of cannulating fistula,
including the Buttonhole technique, and trained others.
The program proved highly successful, with all dialysis
patients with failing grafts converted to secondary fistula by
the year 2000 and all new patients starting dialysis with fis-
tulae. A more recent survey showed that 98 percent of
Nguyen’s patients had fistula, with greatly reduced use of
catheters.
Steps for ChangeAs part of the system change process, Nguyen and his
team noted several things that needed to take place for the
new standard to be a success and recommends them for oth-
ers to consider.
Recognize that this is a team effort. It requires collab-
oration and trust, not just between nephrologists and sur-
geons, but with nursing staff, other dialysis team members,
6 IQ:CKD Spring 2009
primary care physicians, and patients and their families.
The nephrologist must play a central role. In addition to co-
ordinating the effort, nephrologists must have a thorough under-
standing of Doppler analysis and other vein mapping techniques,
surgical options for creating fistula, and cannulating techniques.
Make a roadmap. Establish an outline for the effort.
Prepare for the fistula long before it is needed. Ideally, a re-
ferral should be made at least six months before dialysis is needed.
Establish a relationship of trust with primary care physicians.
Nguyen’s nephrology group started with a letter sent to local pri-
mary care physicians, to encourage early referrals. Building this re-
lationship, according to Nguyen, is "a lot of work; a simple letter is
not going to do it."
Educate patients and their families. Patients don’t want to
hear about the operation when they do not feel sick and yet early
surgery for fistula is key to success. "I spend a lot of time talking to
patients and their families," Nguyen says. "I always invite the whole
family to come to the first visit. Convince the family, and they will
beat on the patient to do it." It’s important to explain the procedure
in very simple terms, he said. "I tell them the [result] is just like
varicose veins, the uglier the better. A fistula is like car insurance:
we hope that we’ll never need to use it, but we’ll be glad to have it
in case of an accident."
Set expectations properly in case the first operation doesn’t do
the job, since we are dealing with sicker and older patients with
higher risk of fistula failure to mature properly, we tell them that
another surgery may be needed. In addition, patients must learn to
protect all veins that may be needed for future fistula construction:
needle sticks are allowed only in hand veins.
Use new surgical approaches when needed. Patients who are
older or obese may need special procedures, including transposition
of deep upper arm veins. Small anastomosis size helps to prevent
steal syndrome (hand ischemia after fistula creation).
Stop revising failing grafts and convert all existing grafts into
secondary fistulas using long term vascular access planning.
Encourage home peritoneal dialysis. Late referral patients are
encouraged to consider home peritoneal dialysis until the fistula ma-
ture in order to avoid the use of hemodialysis catheters which are
the worst dialysis vascular access.
Maintain a checklist for each patient. The AV Access Check-
list for Nephrologists documents key material for a surgical plan,
including mandatory preoperative vein mapping for all patients.
Educate staff. Proper training in AV access is key for all team
members. That’s a particular issue, in Nguyen’s opinion, because
historically "there’s been no training whatsoever in vascular access
for nephrologists and not much for surgeons." Graft cannulation is
very different from fistula. Dialysis staff are more familiar with graft
cannulation, since the majority of vascular accesses in use in this
country are grafts. Training in fistula cannulation is the key of a suc-
cessful fistula program.
Monitor results as part of a comprehensive quality care control
program. Maintain and analyze statistics on AV access by the
nephrologist, surgeon, and dialysis unit to encourage change in prac-
tice behavior.
IQ:CKD Spring 2009 77
8 IQ:CKD Spring 2009
The pressure is on for states and providers to adopt health infor-
mation technology (HIT) and the recently passed economic stimulus
package provides at least partial funding.
Under the American Recovery and Reinvestment Act (ARRA),
approximately $19 billion has been allocated to Medicare and Medi-
caid programs for the purpose of increasing reimbursements to hos-
pitals and physicians who become meaningful electronic health record
(EHR) users.
According to the ARRA, if a physician or hospital becomes a
meaningful EHR user after 2014, they are not entitled to any incentive
payments.
In order to become a meaningful EHR user under the Medicare
program and qualify for full payment of stimulus dollars, providers
must demonstrate that they are using certified EHR technology.
The technology must be connected in a manner that provides for
the electronic exchange of health information to improve the quality
of health and they must submit information on clinical quality meas-
ures.
Incentives will begin in 2011, with those achieving meaningful
adoption receiving incentives for up to five years. The maximum
available for those qualifying in 2011 is $44,000. After 2014, anyone
who treats Medicare patients without an EHR will see reimbursements
decrease by 1 percent that year. The pay cut grows to 2 percent in
2016 and 3 percent in 2017 and every year afterwards.
Last year, Congress applied the same carrot-and-stick approach
to e-Prescribing in the Medicare Improvements for Patients and
Providers Act of 2008 (MIPPA). Those who e-Prescribe in 2009 and
in 2010 qualify for a 2 percent raise based on their total Medicare rev-
enue.
The bonus decreases to 1 percent in 2011 and 2012, to 0.5 percent
in 2013, and then disap-
pears (physicians who
receive the EHR bonus
cannot receive the e-pre-
scribing bonus). MIPPA
also imposes a 1 percent
penalty on physicians
who do not begin e-prescribing by 2012. The penalty increases to 1.5
percent in 2013 and to 2 percent in 2014 and beyond.
Details of the Medicaid health IT dollars are not as clear, but
under the Medicaid incentive program, a larger group of medical pro-
fessionals are eligible for the funds, as long as they serve a sufficient
percentage of Medicaid patients.
Unlike Medicare, which only funds doctors and hospitals, eligible
professionals under Medicaid include a physician, dentist, certified
nurse mid-wife, nurse practitioner, and a physician assistant serving
in rural health clinics or federally qualified health centers. Medicaid
payouts are also more significant.
Across five years, practitioners could collect a sum total of
$64,000. This is a maximum total based on paying up to 85% of ex-
penses for an EHR purchase. The first year reimbursement is equiv-
elent to 85% of up to $25,000 for the purchase of an EHR and each
subsequent year (up to 4) is paid at 85% of up to$10,000.
To be eligible for the Medicaid incentive payout, physicians must
have a 30 percent Medicaid patient case load or 20 percent for pedi-
atricians.
According to a U.S. Department of Health and Human Services
report, only 1.5 percent of hospitals nationwide use an EHR and the
number is in line with Tennessee hospital implementation.
However, e-Prescribing or eRx (the ability to electronically order
prescriptions) use in Tennessee has increased by 749 percent since
2006. During 2008, 1,950 Tennessee healthcare providers issued 1.5
million electronic prescriptions, representing 3 percent of all prescrip-
tions written in the state.
“The sheer number of e-prescriptions speaks volumes to the po-
tential for physicians and hospitals that have yet to implement an
EHR,” said Jennifer McAnally, Health Information Technology Pro-
gram Manager for QSource. “In this instance, time literally is money.
The longer a hospital or physician chooses to wait to implement HIT,
the less money they could receive. QSource has helped 300 physician
offices implement an EHR and e-prescribing.”
Hospitals and physicians interested in learning more about the
Medicare physician HIT stimulus program can contact McAnally at
[email protected] or 800.528.2655 ext. 2635.
As the chief medical officer for the National Kidney Foundation,
Joseph Vassalotti, MD, FASN, is on a mission to “demystify” Chronic
Kidney Disease (CKD), and he believes QSource can be a valued partner
to aid his cause.
Vassalotti, an associate clinical profes-
sor of medicine at Mount Sinai School of
Medicine, helped systematically develop
the Kidney Foundation Outcomes Quality
Initiative (KDOQI) guidelines to assist
practitioner and patient decisions about ap-
propriate healthcare for CKD.
The KDOQI guidelines have improved
the lives of thousands of kidney patients
since their creation in 1997. However, even
more healthcare professionals need to know
about the guidelines; and, that is where
QSource’s assistance is most needed, he
said.
“I believe the QIOs have a great opportunity,” said Vassalotti.
“QIOs can help educate primary care physicians (and their staff) about
the guidelines and provide technical support for primary care practices’
utilization of the KDOQI guidelines.”
Guidelines Help Providers Improve CareThe KDOQI guidelines, which were initially developed because of
the high mortality of patients on dialysis, were needed because of con-
fusion about the disease and its progression. For example, there were 23
different terms used to describe decreased kidney function in abstracts
submitted in 1998 and 1999 to the American Society of Nephrology
(ASN).
“Obviously this was very confusing — even to someone
who knew the field. These terms would not allow for a con-
certed public health approach to CKD,” said Vassalotti. “If
nephrologists could not agree on what CKD is, what could we
do in terms of a public health approach or a patient awareness
approach?”
He said, after more than a decade since the guidelines were
first published, this “nomenclature mess” has been cor-
rected. There is widespread agreement about the def-
inition of CKD and the association of
complications of the disease with stages 1-5
based on GFR levels estimated from serum
creatinine. The clinical practice guidelines
address evaluation, classification, and strat-
ification.
Challenges Still ExistHowever, there are still significant
challenges with the implementation of
the guidelines. On a recent teleconference,
Vassalotti outlined some of the barriers
QSource may be able to help provider and
partners overcome. He shared research that
illustrated poor utilization of CKD testing.
“There were higher rates of glucose and lipid testing than serum
creatinine. These low creatine testing rates suggest the importance of
more physician education,” he explained.
Vassalotti acknowledged some primary care physicians are still con-
fused about CKD testing. However, evaluation of laboratory measure-
ments for the clinical assessment of kidney disease is occurring now.
“A national standardization program is being undertaken by the Na-
tional Institutes of Health (NIH) to standardize serum creatinine testing,”
he said. “There are so many tests that the physician can pick: the NIH is
trying to standardize not only the laboratory measurements but also this
byzantine list of different tests for urinary albumin which is confusing
for primary care physicians.”
He explained that urinary albumin to creatinine ratio is recom-
mended because it is “more quantitative and more accurate than others.”
The QIO’s specific goal is to increase the adoption of evidence-
based standards to identify CKD in Medicare patients through an annual
urinary microalbumin measurement for individuals with diabetes.
Vassalotti’s recommendations are clear. He stressed that CKD is
poorly inferred from serum creatinine alone. He strongly encourages
clinical laboratories to routinely estimate and report GFR when serum
creatinine is measured. Routinely reporting estimated GFR (eGFR) with
all serum creatinine determinations helps identify reduced kidney func-
tion for providers, and thus facilitates the detection of CKD.
“It is very important that these tests are to be used together. These
are complementary tests — not alternative tests — you can’t substitute
one for the other. GFR is not the
only test,” said Vassalotti.