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• W2113643058 abstract "See related article on page 647. When I served as a member of the Ad Hoc Committee on Nephrology Manpower Needs,1Neilson E Hull A Wish J Neylan J Sherman D Suki W Ad Hoc Committee on Nephrology Manpower Need The Ad Hoc Committee Report on Estimating the Future Workforce and Training Requirements for Nephrology.J Am Soc Nephrol. 1997; 9: S1-S32Google Scholar it was evident that the number of nephrologists needed to care for the growing end-stage renal disease (ESRD) population by the year 2010 would not be sufficient based on the current nephrology fellowship training output. This conclusion was based on the premise that nephrologists would continue to operate in the same manner over the next decade as we have done for the past many years. If one accepts that premise, then we will have a deficit of nephrologists to care for the increasing aged population with renal failure. Also, it is now evident that there will not be an increase in the number of nephrology fellowship training positions allocated by the Accreditation Council for Graduate Medical Education. In fact, there has been an 8% decrease in the number of nephrology slots since 1995, which is consistent with the government's emphasis on increasing primary care training and decreasing the number of medical specialists.2Steinman TI HMO's and ESRD: A gloomy scenario.Nephrol News Issues. 1998; 12: S30-S33Google Scholar Therefore, changes are needed in our approach, and solutions need to be recommended. In this issue of the American Journal of Kidney Diseases, Anderson et al3Anderson JE Torres JR Bitter DC Anderson SC Briefel GR Role of physician assistants in dialysis units and nephrology.Am J Kidney Dis. 1999; 33: 647-651Abstract Full Text Full Text PDF Scopus (13) Google Scholar have detailed the role of physician assistants in dialysis units and nephrology. The conclusion of the article is that nephrology is not maximally utilizing physician assistants and nurse practitioners. Bender and Holley4Bender F Holley J Most nephrologists are primary caregivers for chronic dialysis patients: Results of a national survey.Am J Kidney Dis. 1996; 28: 67-71Google Scholar discovered via their questionnaire that only 21% of nephrologists currently use physician assistants. Although it is critical to maximize the use of physician extenders to care for the ESRD population, a more broad-scale approach is needed to address the anticipated shortfall in the number of nephrologists. Let us view alternative solutions to provide care to this chronically ill population. ESRD is the ideal chronic disease state amenable to disease management, because it is easily definable by the need for renal replacement therapy. Frequent patient contact allows for collection of reliable data and the ability to assess the impact of any change in intervention. Disease management encompasses an integrated team approach to patient care. If one visualizes the patient at the center of a hub of a wheel, every caregiver must directly relate to that patient as well as to each other via informatics.5Steinman TI Administrational and organizational aspects of dialysis.in: Clinical Nephrology, Dialysis and Transplantation. Dustri-Verlag, Deisenhofen Dei München, Germany1999: 1-19Google Scholar Therefore, nephrologists, nursing staff, rehabilitation specialists, social worker, dietitian, renal administrator, technician/support staff, and health care coordinator must interact while focusing continuously on delivering quality care to the ESRD patient. Integrated care encompasses pre-ESRD medical care, options teaching (for hemodialysis, peritoneal dialysis, and transplantation) as the patient progresses towards renal failure, and creation of access at an appropriate early time to allow full maturation before initiation of dialysis (favors placement of arteriovenous [AV] fistulas). At the same time, social service input will help the patient deal with insurance and psychosocial issues surrounding ESRD. Rehabilitation before dialysis will focus on vocational, physical, and occupational approaches specifically designed for patients with chronic renal failure. The goal at all times is to keep the patient employed in the workplace before the beginning of dialysis. If employment ceases for medical reasons before the start of dialysis, there is less than a 10% chance that the person will return to the workplace.6Curtin R Oberley ET Sacksteder P Differences between employed and unemployed dialysis patients.Am J Kidney Dis. 1996; 27: 533-540Google Scholar However, continued employment as ESRD approaches will greatly increase the possibility that such employment will be sustained after the dialysis treatment course has been stabilized. Once dialysis is initiated, then consideration can be given to such issues as transportation, home health services (durable medical equipment), chronic care placement (if needed), and home dialysis possibilities. Health service coordinators, who truly are care coordinators, become a valuable asset to the team by their ability to integrate all components of care. These care coordinators, usually experienced nurses, are the newest members of the health care team and they can be the “glue” that closes the gaps between other caregivers. Home visits by these individuals allow a more complete look at patient care, which ensures a greater likelihood of compliance with medications, diet prescriptions, fluid management, diabetes control, and so on. At the same time, these senior nurses can coordinate the many components of care that face the patient with ESRD (eg, radiology scheduling, physical therapy appointments, and other medical specialty consultations). A physician's time can be saved by delegating responsibilities to these health service coordinators. An example of appropriate utilization of these colleagues is vascular access, either planning for new creation or dealing with complications of existing accesses. These care coordinators can handle urgent referrals to the interventional radiologist, interventional nephrologist, or vascular surgeon. Vascular access monitoring programs can be directed/coordinated by these individuals. Hopefully, access monitoring will decrease the number and severities of access complications. If physicians are members of such a team, then quality care can be delivered without an increase in the number of nephrologists. Success requires that nephrologists relearn how to participate in a fully integrated care delivery system. The team establishes goals and develops methods for achieving tasks. Implementation requires a responsible team member to take charge of a specific aspect of care and then communicate results to every member of the team. Improvement in our information delivery systems is critical for the ultimate success of an integrated system. Continuous quality improvement is the driving force behind quality care. Collection and reporting of appropriate patient data that impact on outcomes must be performed on a regular basis. Health service coordinators can be responsible for this critical task. Results are fed back to the nephrologists so they can assess their performance and then undertake any necessary changes in the dialysis/medical care prescription. One must recognize factors that drive a reduction in costs and improve outcomes. There must be a presentation of valid patient data to nephrologists and dialysis providers to facilitate improvement. The care coordinators can be the individuals who monitor the changes in total care delivered to the patient. Payment methodology should be directed toward incentive reimbursement for quality care. There should never be an incentive payment focused primarily on reduction of cost, only for improving care. Nephrologists and their team members with the best outcomes should receive bonus payments. High-quality care costs the least in the long run. Changes in reimbursement most probably could not occur unless there is a global capitation methodology.7Steinman TI Managed care, capitation and the future of nephrology.J Am Soc Nephrol. 1997; 8: 1618-1623Google Scholar New approaches to achieve economy of scale and improve outcomes would be to develop vascular access centers, improve outpatient management for congestive heart failure patients, and achieve better metabolic management for diabetic patients. Algorithms for aspects of care have shown improved outcomes.8Patterson P Allon M Prospective evaluation of an anemia treatment algorithm in hemodialysis patients.Am J Kidney Dis. 1998; 32: 635-641Abstract Full Text PDF Scopus (21) Google Scholar Practice guidelines and best demonstrated practices can be reduced to algorithms that simplify decision making. The end result is more efficient use of time for all caregivers. If the previously mentioned system is implemented, some predict that within 1 to 2 years costs of ESRD care will go down and quality of care will improve. If we evaluate the process of care and continue to focus on the well being of the patient, improvement is inevitable.9Holley JL Monaghan J Beyer B Brother O An examination of the renal transplant evaluation process focusing on cost and the reasons for patient exclusion.Am J Kidney Dis. 1998; 32: 567-574Abstract Full Text PDF Scopus (45) Google Scholar, 10Shidler NR Peterson RA Kimmel PL Quality of life and psychosocial relationships in patients with chronic renal insufficiency.Am J Kidney Dis. 1998; 32: 557-566Abstract Full Text PDF Scopus (106) Google Scholar No more nephrologists than are currently in the system and in the pipeline will be needed if we change our delivery system, even though additional surveys emphasize more nephrologists will be needed to care for the projected increase in dialysis patients.11Mitch W McClellan WM Patterns of patient care reported by nephrologists: Implications for nephrology training.Am J Kidney Dis. 1998; 32: 551-556Abstract Full Text PDF Scopus (13) Google Scholar Because we cannot expect a sudden increase in the number of residents who take nephrology fellowships, we must adapt to new approaches to integrated care. Subspecialty training in nephrology implies that professional patient-care time must be devoted to nephrological care. General internal medicine should not be the purview of the nephrologist unless it deals with the care of a nephrology patient.12Glassock RJ Nephrology workforce and time allocation: Important issues for the future.Am J Kidney Dis. 1998; 32: 672-675Abstract Full Text PDF Scopus (6) Google Scholar" @default.
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