outcomes associated with a disease management program for end-stage renal disease

Outcomes Associated with a DiseaseManagement Program for End-Stage Renal Disease

Allen R. Nissenson

Department of Medicine, Division of Nephrology , UCLA School of Medicine, Los Angeles, California, USA

Abstract Disease-state management is gaining in use for the management of chronically ill individuals including thosewith diabetes mellitus, congestive heart failure, asthma, and some forms of cancer. Recently, disease manage-ment (DM) has been applied to patients with chronic kidney disease (CKD), a growing population of patientswith high annual costs. CKD is ideally suited to DM since the definition of the condition is unambiguous andcurrent care is highly fragmented. There are currently over 240 000 patients receiving dialysis for end-stagerenal disease (ESRD), with projected numbers of nearly 600 000 by 2010, and nearly 9 million individuals withCKD not yet on dialysis. The total cost of care for patients with ESRD alone exceeded $US17 billion in 2000.Over 40% of costs for patients with ESRD result from hospitalizations, many of which can be avoided. Inaddition, much of the clinical morbidity and cost relates to associated comorbidities rather than ESRD per se,with little management presently provided for these conditions in the dialysis facility setting.

DM for CKD uses field-based nurse care managers who can risk-assess patients and provide coordinationof care so that the renal issues as well as comorbidities are identified and appropriately managed. Although fewresults from such efforts have been published, those that have, from RMS Disease Mnagement Inc., showremarkable improvements in a variety of clinical outcomes including mortality and hospitalization.

Challenges to expanding DM for CKD include up-front funding to provide the needed DM, the availabilityof robust information systems to manage and analyze clinical and financial data, and the interest and participationof nephrologists, primary care providers and dialysis facilities, as well as other key providers to ensure that theDM approach is effective. With continuing increases in the number of patients with CKD in managed healthplans, DM for this population will be even more important in the future to optimize clinical outcomes whileconstraining the costs of care.

LEADING ARTICLE Dis Manage Health Outcomes 2002; 10 (2): 93-1001173-8790/02/0002-0093/$25.00/0

© Adis International Limited. All rights reserved.

In the early 1990s, targets for disease management (DM) werehigh volume, common, chronic conditions such as coronary arterydisease, hypertension, asthma, and diabetes mellitus.[1] This focushas since expanded to managing diseases that significantly impactthe cost to health systems, as well as those for which the qualityof care can be substantially improved.

Disease management today is establishing processes of carefor chronically ill and disabled patients, as well as developingmetrics to determine if these processes are effective in improvingquality and constraining costs. These include:• identifying at-risk individuals through regular screening programs

• systematically tracking the care plan of identified patients• providing coordinated care through multidisciplinary team-

work• reporting outcomes data on care for a specific population• maintaining core competencies especially as they relate to

caring for the chronically ill.This article illustrates the need for DM in the care of people

with chronic kidney disease (CKD), outlines strategies for imple-menting such programs, and offers clinical outcomes and a casestudy of one DM organization’s experience of coordinating thecare of people with this condition.

1. Need for Disease Management in Chronic Kidney Disease (CKD)

CKD is an ideal condition in which to implement a DM model[2]

because of the combination of: (i) the medical complexity of peo-ple with CKD; (ii) the high prevalence of serious comorbidconditions; (iii) the predictable and continuing requirements forcostly patient care services over a defined period of time; and (iv)the known variations in processes of care and outcomes. The factthat there is fragmented care, with various caregivers (dialysisunits, physicians, laboratories, hospitals) all operating as inde-pendent clinical and profit centers, contributes to the suboptimaloutcomes and significant costs for this group of patients duringthe stages of CKD, as well as following the development of end-stage renal disease (ESRD).

In today’s environment, the fragmented structure of health-care delivery is being replaced with one that supports coordinatedand comprehensive patient-centered care. While this is becomingmore common with chronic diseases such as diabetes mellitusand congestive heart failure, it is just beginning for patients withCKD. Managing a health plan’s CKD population, in this manner,assumes total responsibility for all of the patients’ healthcare needs.Using the nephrologist as the center of the patient’s care team, anetwork of resources ensures that patients with CKD receive thebest-coordinated care possible. In a fully integrated, well-run DMorganization, seven major components combine to provide thehighest quality of care at the most reasonable cost:• patient risk assessment• individualized care plan development• patient monitoring• preventive intervention• patient compliance and education programs• established protocols, pathways and outcomes management• utilization management and review.

ESRD, the end point of CKD, is the only specific diseasestate in the US for which outpatient care for the facility (dialysisunit) and physician (nephrologist) is paid for on a capitated basisby Medicare. Historically, commercial payors did not need tofocus on the care provided to patients with ESRD. The growthof the ESRD patient population, however, has been the primarycause of increasing expenditures, resulting in total ESRD pro-gram costs exceeding expectations and driving Medicare pay-ment policy. After 18 months of commercial coverage, Medicareautomatically covered patients with ESRD.[3] With the onset ofthe Balanced Budget Act of 1997, Medicare increased the ‘wait-ing period’ during which commercial carriers must fully cover arenal patient’s medical costs to 30 months. This caused a 67%cost increase to health plans in 1998 for patients with ESRD (per-

sonal communication, A. Collins M.D., Nephrology AnalyticalServices, Minneapolis, Minnesota, June 2001).

Treatment costs for individuals with ESRD can reach be-tween $US50 000 and $US100 000 annually. The cost for a planwith 1 million members can top $US50 million per year. Esti-mated total Medicare costs for ESRD were $US12.7 billion in1999.[4] Hospitalizations account for 36.5% of ESRD costs, andpeople with ESRD average 12 to 15 inpatient days per year. He-modialysis vascular access procedures and associated costs rep-resent 25% of total ESRD medical costs. Improving the way peo-ple with ESRD are managed can prevent financial disaster for thepayor. In addition, identifying and managing patients with CKDbefore they reach ESRD will further improve the quality of care,and decrease the costs of care, once ESRD develops. CKD DMprograms focus on identifying and treating the complications ofCKD (e.g. anemia or renal osteodystrophy) and its associatedmedical comorbidities [e.g. diabetes, hypertension, and conges-tive heart failure (CHF)], and smoothing the transition toESRD (e.g. outpatient access placement, preferably with an au-tologous arteriovenous fistula, and initiation of dialysis in the outpa-tient setting).

Because of the high burden of illness related to CKD, healthplans are beginning to outsource the management of patients withCKD to experienced DM organizations. In addition, the HealthCare Financing Administration [now the Center for Medicareand Medicaid Services (CMS)] has recently completed an ESRDManaged Care Demonstration project, with the results soon to beavailable. Finally, a new demonstration project was recently an-nounced by CMS to evaluate the effects of coordinated care pro-grams, including disease management, on Medicare patients withdiabetes mellitus, CHF, and other non-renal chronic diseases.

Managed care today is just beginning to gain valuable expe-rience with regard to efficiently and effectively treating patientswith CKD. The level of care necessary to maintain a patient’shealth is unique when compared with other more common chronicdiseases that are targets for DM. With this background, what spe-cific characteristics of CKD make it particularly suitable for theapplication of disease management?

2. Why is Disease Management ParticularlyBeneficial in the Care of Patients with CKD?

CKD is (by definition) irreversible and may be a very de-bilitating condition. Although medical management tech-niques may slow the progression of the disease (e.g. protein re-striction and the use of ACE inhibitors), ESRD develops ina significant number of patients. ESRD, of course, must betreated with dialysis or kidney transplantation. Because of a se-

94 Nissenson

© Adis International Limited. All rights reserved. Dis Manage Health Outcomes 2002; 10 (2)

vere shortage of donor organs for transplantation, dialysis is themost common option utilized. Patients with ESRD almost in-variably have multiple comorbid conditions that require veryspecific care management and these may be more importantdrivers of clinical outcomes and cost than the renal diseaseitself. To improve overall care, therefore, the following areas mustbe optimally managed:• adequacy of dialysis• anemia• calcium/phosphorus metabolism• metabolic acidosis• nutrition• lipid disorders

• vascular access• hypertension• CHF• diabetes mellitus• wounds.

At the end of 1999, there were about 344 320 people in theUS being treated for ESRD. Over 240 000 of these people are ondialysis. This large prevalent population is maintained by a grow-ing incidence rate, which is in excess of 89 000 people per year.[4]

People with CKD not yet on dialysis have a high prevalenceof diabetes mellitus, hypertension, and CHF, including those pa-tients in whom the etiology of CKD is an intrinsic kidney diseasesuch as autosomal dominant polycystic renal disease (ADPKD)or chronic glomerulonephritis. The prevalence of advanced CKD(glomerular filtration rate about 30 ml/min or less) is estimatedto be four to seven times higher than that for ESRD.[3] The federalgovernment presently covers about 75% of the costs for ESRD.Disorders such as diabetes mellitus (the primary precursorfor ESRD) and hypertension currently account for approximately10% of all commercial health plan expenditures.

The goal of caring for patients with CKD is to apply inter-ventions early enough to produce net quality and cost benefits;

Table I. Features of disease management for various stages of chronic kidney disease (CKD). Reproduced from Tompkins et al., with permission fromBlackwell Publishing[5]

Feature of disease management Stage of the disease

preclinical chronic kidney diseasea ESRD

Clinical threshold Serum creatinine (mg/dl): <1.5(females); <2.0 (males)

Serum creatinine (mg/dl): ≥1.5(females); ≥2.0 (males) ≥4.0(predialysis)

Kidney failure Transplant or onset of dialysis

Chief clinical goals Primary preventionManage precursor conditions andcomorbidities, if present (e.g.diabetes, lipids, glucose)

Secondary prevention Retard progression Improve nutrition Maintain functioning Prepare for dialysis or transplant

Tertiary prevention Avoid complications

Critical interventions Proper diet Exercise Routine physician examinations,including serum creatinine levels

Control precursor conditions Avoid nephrotoxic substances Patient education Erythropoietin (epoetin; EPO) Patient education – renal replacementmodalities Prepare vascular access

Transplantation Hemodialysis Peritoneal dialysis

Coordinating physician Primary care physician Nephrologist Other primary care physician(optional)

Nephrologist

Other caregivers (As needed, based on risk statusand existing conditions)

Multidisciplinary team includingpharmacist, dietitian, vocationalcounselor, mental health provider,social worker, case manager, vascularsurgeon, transplant team

Multidisciplinary team Dialysis providers

a Italicized entries reflect advanced chronic kidney disease, sometimes referred to as ‘predialysis’.

ESRD = end-stage renal disease.

Table II. Incidence of end-stage renal disease, 1990 to 1999[4]

Age (years) Incidence (rate/million population)

1990 1999

≥75 675 1434

65-74 823 1317

45-64 393 603

20-44 100 119

0-19 14 15

End-Stage Renal Disease 95


the interventions usually take the form of an emphasis on preven-tive care, patient and family education, and self-management.DM, therefore, is appropriate for the various stages of CKD, butthe approaches/interventions vary depending on the level of renalfunction and presence of comorbidities (table I). In this table weuse serum creatinine level as the marker of CKD. It would bemore accurate to use calculated glomerular filtration rate (GFR),when possible. The stages of CKD will be defined on the basis ofGFR in a clinical practice guideline being developed as part ofthe Kidney Disease Outcomes Quality Initiative (K/DOQI) of theNational Kidney Foundation, to be released in 2002.

3. Unique Characteristics of Patients with CKD

Not only is the number of patients with CKD growing, butthose that are identified are increasingly older and more complexmedically. Of the 240 000 patients on dialysis in the US at the endof 1999, 9.4% are on peritoneal dialysis and the remainder are onhemodialysis. The incidence of ESRD was 317/million popula-tion and the prevalence was 1217/million. By the end of 2010, itis estimated that there will be over 500 000 patients on dialysisin the US.[4]

Table II shows that the incidence of ESRD increased from1990 to 1999 in most age groups, but that the incidence in peopleaged 65 years and older is increasing more rapidly compared withyounger age groups. The ESRD incidence in 1999 for the 65- to74-year age group was 1317/million population, with more than a50% increase in the rate compared to 1990, and over 10 times theincidence for the 20- to 44-year age group. The most rapidly growingportion of the ESRD population is the elderly. In fact, since 1996,enrollment of the elderly with ESRD into managed-care plans hasgrown from 4 to 8%.[6] The elderly usually present with increasingprevalence of diabetes mellitus and hypertension, making them

more medically complex than the average patient who has beenseen in the past.

Areas requiring particular attention in this complex CKDpopulation include:• strategies to improve care in a managed-care setting, espe-

cially for the elderly population• identification of patients placed on and withdrawn from di-

alysis• attention directed toward CKD care in order to prevent or

slow the rate of progression of ESRD• DM for patients with CKD, especially the elderly• costs of patient care.

4. Strategies for Managing CKD

Strategies for managing CKD include delaying the onsetof ESRD, avoiding complications requiring hospitalization, im-proving health status and outcomes of ESRD therapy, selecting atreatment modality based on outcomes data, and organizing sys-tems of care with emphasis on matching expertise with clin-ical need.

5. Challenges Faced in Implementing DiseaseManagement Programs

Physicians and ESRD care managers are challenged by howto optimize these DM strategies for CKD, which are appliedon a population basis rather than to illness episodes.[7] Effectivequality and outcomes management programs require that every-one on the clinical care team engages in a continuous effort toraise the level of performance and quality of care. Frequent com-munication with mutually understood terminology is important.Early identification of the population at risk is key to reduc-ing the incidence of ESRD. Once patients are identified, clinicalguidelines and pathways for care can be applied in a practice

Table III. Dialysis issues to be addressed by the care team. Reproduced from Steinman, with permission from Dustri-Verlag[10]

Task How achieved Primary responsibility

Dialysis prescription Establish goals Nephrologist

Dialysis delivery Each treatment Nursing/technical staff

Adequacy of dialysis Monthly review of laboratory data Nephrologist

Social service Monthly review Social worker

Nutrition Monthly review of laboratory data Dietitian

Rehabilitation

physical Establish goals Physical therapist

occupational evaluation of home needs Occupational therapist

vocational Employment status Rehabilitation commission

Scheduling Written/verbal communication Head nurse and secretary

Water treatment Maintenance schedule Technician

Supplies Order schedule Renal administrator

96 Nissenson


model that reduces cost and delays the progression of the disease.Focusing the care delivered by multiple providers in disparatesettings is the real challenge and the promise of DM for patientswith CKD.

6. The Role of the Nephrologist and Other CareTeam Members

Successful CKD DM relies upon the full involvement of thenephrologist. Nephrologists can deliver more cost-effective carefor patients with CKD than internists/generalists.[8,9] Access tothe nephrologist before ESRD develops can lead to a slowing ofthe progression of CKD, identification and treatment of compli-cations of CKD and associated comorbidities and can better pre-pare the patient for eventual dialysis. Care management supportsthe role of the nephrologist as the primary caregiver. A DM ap-proach helps to ensure a healthier patient, and realize reducedcosts as a result of reduced hospitalization and lower mortalityrates. Table III shows dialysis issues that need to be addressed ona regular basis by the patient’s care team. Similar issues are de-scribed for the patient with CKD not on dialysis in table I.

7. Nephrologist-Specific Issues

As nephrologists become more involved with DM, they needto understand how they are integrated into such a delivery system.Some of the questions and concerns that nephrologists have ex-pressed in this regard include:• the potential lack of control over the management of their

patients’ care• the inevitability that they will do more work with less oppor-

tunity for income• the obvious decrease in their income as hospitalizations are

reduced• the legal implications of incentives offered to them by payors.

The question is whether nephrologists will accept their roleas it changes in this new DM environment. Will the nephrologist

be able to function as the leader of the care delivery team,addressing not only the CKD/ESRD–related medical issues, butalso directing the identification and management of comorbidconditions that may be critically important in driving outcomesand costs?

8. Comprehensive Patient-Centered Care is Keyto CKD Disease Management

As fragmented healthcare delivery systems transition to asingle DM system supportive of coordinated and comprehensivepatient-centered care, managing a health plan’s CKD populationrequires an assumption of total responsibility for the patient’shealthcare needs. Positioning the nephrologist as the center of thepatient’s care team, and providing access to a network of neededresources that are all coordinated by the care manager, help toensure that patients receive the most appropriate and efficient carepossible.

9. Field-Based Care Coordinators

Care coordinators are an essential component of successfulDM programs. Although not all renal DM programs have field-based care coordinators (often referred to as care managers and/orhealth service coordinators), there are many advantages to havingthem. These individuals are preferably registered nurses experi-enced in renal care. In contrast to a ‘case’ manager – who focuseson cost, complex illness, and acute management – care coordina-tors are ‘care’ managers, doing more than following a patient’s ‘case’.

Typically, a care coordinator is responsible for:• serving as the ongoing contact person for the patient, provid-

ing personal continuity for patients who see professional car-egivers in various locations

• performing a complete direct assessment of the patient, bothinitially and as the patient’s care continues

• keeping progress notes that are recorded in the patient’s record

0

20

40

60

80

10084.0

CPM '00

87.0

Q3 '98

88.3

Q4 '98

93.8

Q1 '99

93.2

Q2 '99

91.6

Q3 '99

93.1

Q4 '99

92.5

Q1 '00

93.4

Q2 '00

93.1

Q3 '00

91.9

Q4 '00

Per

cent

age

of p

atie

ntm

onth

s w

ith K

t/V ≥

1.2

Fig. 1. Percentage of patients managed by RMS Disease Management Inc. with a dialysis dose equaling or exceeding that currently recommended by the NationalKidney Foundation Kidney Disease Outcomes Quality Initiative (K/DOQI), by quarter of data collection, and demonstrate substantial improvement over time and comparedwith the benchmark core indicators data. Kt/V = normalised dose of dialysis.



• collecting and recording data throughout the patient’s courseof care, with focus on quality indicators, benchmarks andperformance standards

• interacting directly with patients based on an initial and on-going risk assessment (high-risk patients are contacted dailyby phone and are visited weekly in their homes, in the hos-pital, or in a dialysis unit to review laboratory reports, ensurecompliance with diet and medications, and answer questionsor resolve problems)

• being available to patients 24 hours a day, 7 days a week• working with the responsible nephrologist to plan a course

of action for the patient• participating in regional or local quality teams of leading

nephrologists, vascular surgeons, dialysis nurses and healthplan representatives to identify care trends in the communityand to develop quality improvement initiatives for patientsin the DM program.

10. Clinical Information Systems

Medical management and operational systems of the DMprogram are driven by the collection and analysis of comprehen-sive clinical and financial data. Data need to be available to thepeople primarily responsible for coordinating a patient’s care.Clinical data can come from the patient, nephrologist, primary

care physician, dialysis center, insurance carrier, and the hospital

(if the patient has been admitted or has visited the emergency

department). Coordinating this information requires a compre-

hensive, integrated software system that allows a patient’s care

manager access, in one central database, to all of the details re-

garding a patient’s medical care, no matter where the care is de-

livered. Such systems are extremely complex and costly to de-

velop, and must be overseen by a well-trained and dedicated staff

if they are to be fully functional.[11]

11. Patient Participation in Disease Management

Adaptation to CKD and ESRD is difficult for most people.

An effective DM program ensures patient compliance with the

medical management and dialysis regimen, helps patients under-

stand necessary dietary and medication requirements, and helps

patients adapt to lifestyle changes, which can be severe. Care

coordinators provide kidney disease education and support to pa-

tients and providers that include identifying and avoiding com-

plications that often result in hospitalizations. A well informed,

engaged patient is essential to the success of a DM program.

0

0.5

1.0

1.5

2.0

2.5

3.0

3.5 3.2

USRDS'00

2.1

Q3 '98

2.29

Q4 '98

1.79

Q1 '99

1.75

Q2 '99

1.91

Q3 '99

1.6

Q4 '99

1.8

Q1 '00

1.6

Q2 '00

1.7

Q3 '00

2.0

Q4 '00

Bed

day

s pe

r pa

tient

Fig. 2. Bed days per patient managed by RMS Disease Management Inc. per quarter in consecutive quarters of data collection, demonstrating a marked decrease overtime and a substantially lower number of days compared with data from the U.S. Renal Data System (USRDS).[4]

00.020.040.060.08

0.100.120.140.16 0.15

Q3 '98

0.05

Q4 '98

0.06

Q1 '99

0.05

Q2 '99

0.05

Q3 '99

0.05

Q4 '99

0.05

Q1 '00

0.04

Q2 '00

0.04

Q3 '00

0.02

Q4 '00

ER

vis

its p

er p

atie

nt

Fig. 3. Emergency room (ER) visits per patient managed by RMS Disease Management Inc. per quarter, illustrating the rapid reduction in visits that occurs when adisease management program is introduced.[4]

98 Nissenson


12. Patient Outcomes in Kidney DiseaseManagement Programs

Specific quality-of-care outcomes and level-of-performancemeasures drive continual improvement and provide the momen-tum necessary for DM programs to succeed. Figure 1, figure 2,figure 3, and figure 4 illustrate some of the clinical indicators thatare tracked by RMS Disease Management Inc., currently the larg-est and most experienced renal DM organization. Other outcomestracked include patient satisfaction and quality of life, the latterbeing measured using the Kidney Disease Quality-of-Life instru-ment (KDQOL-SFTM).

RMS has recently published its national data on survivaland hospitalizations, showing a standardized mortality ratio andstandardized hospitalization ratio (total hospitalizations) signifi-cantly lower than 1, indicating improved survival and a lowerlikelihood of hospitalization in patients managed by RMS Dis-ease Management Inc. compared with the general ESRD popula-tion reported by the U.S. Renal Data System (USRDS).[12]

13. Case Study

Humana Health Plans of Kansas City, Missouri, USA, a man-aged healthcare company that insures about 136 500 health planmembers and employs about 600 associates, has achieved impres-sive results with DM. On the basis of analysis by RMS DiseaseManagement Inc. of their own data, outcomes for Humana mem-bers with ESRD in Kansas City were substantially better thannational benchmarks in almost every category measured (resultspublished in abstract form only to date).

Results were compared for Humana’s members to bench-marks established by CMS and the USRDS, a government data-base of more than 340 000 patients with ESRD in the US. Thedata showed the positive impact that DM has on these patients asfollows:• adequate dialysis was achieved for 92% of members com-

pared with the core national average benchmark of 84%• incidence of significant anemia in members was 27% com-

pared with the national average of 32%• hospital admission rate was 0.33 admissions per patient per

quarter for members compared with a national average of 0.38• hospital bed days for Humana members were 2.0 days per

patient per quarter compared with the national average of 3.5days per quarter

• average length of hospital stay for members was 5.1 dayscompared with the national average of 7.5 days

• Humana members with ESRD were 84% completely or verysatisfied with their nephrologist.

14. Conclusions

Renal disease is ideal for the application of a DM model. Thepopulation with ESRD is easily identifiable, methods are beingdeveloped for identifying patients with CKD, and the stages ofdisease and treatment requirements are well defined. Quality-of-care and financial advantages to applying DM on a populationbasis to CKD care will increase its popularity into the future.Strategies for managing renal disease will continue to include:• delaying the onset of ESRD• avoiding complications of CKD and medical comorbidities• minimizing the need for hospitalizations• improving health status and outcomes of kidney disease ther-

apy• selecting an ESRD treatment modality based on patient needs.

The goal is to optimize clinical outcomes while constrainingthe costs of caring for this ill and vulnerable population. This newparadigm in the care of patients with CKD is ideally positionedfor the challenges of healthcare delivery in the new millennium.

Acknowledgements

The work of Dr Nissenson is supported in part by the Richard RosenthalDialysis Fund. Dr Nissenson is Medical Director of RMS Disease Manage-ment Inc.

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(MA): National Managed Health Care Congress, 19972. Blumenthal D, Beeuwkes Buntin M. Carve outs: definition, experience, and choice

among candidate conditions. Am J Manag Care 1998; 4 Suppl.: SP45-57 3. Nissenson AR, Rettig RA. Medicare ESRD program. Health Affairs 1999 Jan/Feb; 18

(1): 161-794. U.S. Renal Data System. USRDS 2001 Annual Data Report: Atlas of end-stage

renal disease in the United States, National Institutes of Health, National Insti-tutes of Diabetes and Digestive and Kidney Diseases, Bethesda (MD), 2001

0.0

0.5

1.0

0.8

1.0

1999 standardizedmortality ratio

0.5

1.0

1999 standardizedhospitalization ratio

USRDSRMS

Fig. 4. Standardized mortality ratio and standardized hospitalization ratio (total)for patients managed by RMS Disease Management Inc. (RMS) compared withpatients in the U.S. Renal Data System (USRDS) after adjustment for age, gender,race, and presence of diabetes mellitus. Reproduced from Nissenson et al., withpermission from WB Saunders.[12]



5. Tompkins CP, Bhalotra S, Trisolini M, et al. Applying disease management strat-egies to Medicare. Milbank Q 1999; 77 (4): 461-84

6. Steinman TI. The challenges of geriatric nephrology managed care/disease man-agement. Geriatric Nephrol Urol 1999; 9: 115-21

7. Bahr T, Burke M, Carey N, et al. Integrated renal disease management: a provider.Dialysis and Transplantation 1997; 26 (4): 123-30

8. Jungers P, Zingraff J, Page B, et al. Detrimental effects of late referral in patientswith chronic renal failure: a case-control study. Kidney Int 1993; 43 (41Suppl.): S170-3

9. Ifudu O, Dawood M, Homel P, et al. Excess morbidity in patients starting uremiatherapy without prior care by a nephrologist. Am J Kidney Dis 1996; 28: 841-5

10. Steinman TI. Organizational and administrative aspects of dialysis. In: MullucheH, Sawaya P, editors. Updated textbook of clinical nephrology, dialysis andtransplantation. Desenhofen, Germany: Destri-Verlag Publishers, 1998: 1-19

11. Mattern W, Scott S. Design and implementation of a fully integrated clinicalinformation system to support management of end-stage renal disease (ESRD).Dis Manage Health Outcomes. In press

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About the Author: Prof. Allen R. Nissenson, MD, FACP, is a Professor ofMedicine and the Director of the Dialysis Program at the University of Cal-ifornia, Los Angeles, USA. Dr Nissenson was recruited to UCLA in 1997,where he has developed a comprehensive dialysis program with significantcomponents including administration, patient care, teaching and research.Dr Nissenson has served as Chair of the Southern California End-Stage Re-nal Disease (ESRD) Network, and Chair of the Council on Dialysis of theNational Kidney Foundation. He has long been concerned with issues ofhealthcare delivery, and has consulted for the Rand Corporation on ESRDand Pacificare on the development of chronic disease management modelsfor ESRD patients. Dr Nissenson is currently the Medical Director of RenalManagement Strategies, the Baxter disease-state management company forrenal disease, and Chair of the Medical Advisory Board of RMS Lifeline. DrNissenson recently completed service as a Robert Wood Johnson HealthPolicy Fellow for the Institute of Medicine, serving in the office of SenatorPaul Wellstone, and is currently the Immediate Past-President of the RenalPhysicians Association. He is the editor of two dialysis textbooks and hasjust completed his term as the editor-in-chief of Advances in Renal ReplacementTherapy, a new journal of the National Kidney Foundation.Correspondence and offprints: Dr Allen R. Nissenson, Department of Med-icine, Division of Nephrology , UCLA School of Medicine, 200 UCLA Med-ical Plaza, Suite 565, Los Angeles, 90095-6945, USA.E-mail: [email protected]

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outcomes associated with a disease management program for end-stage renal disease

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