Chronic kidney disease (CKD) is defined as the permanent loss of kidney function — of varying degrees. CKD may be caused by high blood pressure, diabetes, another disease process, or may even be caused by physical injury.1
The number of Americans with CKD has skyrocketed over the last few decades; there are now more than 20 million citizens who suffer from kidney disease. And between the years 1990 and 2000, the number of people with kidney failure more than doubled to 380,000.
Dialysis adds staggering costs to healthcare in the United States, reaching $33 billion in 2004.2 Although money is not the primary motivation for preventing the need for dialysis, it can be very cost effective to avoid or postpone end-stage renal disease (ESRD).
Not only that, but treating CKD — as well as the causes and complications related to it — is essential, said Dr. Ruth C. Campbell, a nephrologist at the University of Alabama at Birmingham Health System and the director of the hospital’s CKD clinic. By treating the disease, physicians can delay the need for dialysis, and can even improve CKD. In fact, said DaVita Inc., “With early diagnosis, it may be possible to slow, stop, or even reverse CKD, depending on the cause.”3
CKD Clinics in Practice
CKD clinics serve an important function, treating the disease and attempting to slow or stop the process, while also treating the complications and other diseases that often accompany CKD, such as hypertension and diabetes.
The Kirklin Clinic at the University of Alabama at Birmingham opened several years ago, and expanded from a single-function program. “Our overall goal for the clinic was to provide assistance to our nephrologists at UAB to help them meet treatment goals for their patients,” said Campbell. “That’s not to say they couldn’t do it; it’s just that the clinics are very busy, and this would be a parallel, physician-extended clinic to allow them to meet those goals. From the patient’s perspective, I think it’s very helpful because the focus on the clinic is education for the patient. We give them a lot of education why meeting these goals is important, in particular, high blood pressure, reducing proteinuria, trying to treat the complications of CKD, and some diabetes education.”
There is even the option to receive pharmacology counseling, to help the patients deal with the side effects of their treatment.
Other CKD clinics offer similar options — CKD monitoring, nutrition counseling, anemia management, education for the patients, and treatment of comorbidities such as hyperlipidemia.
Exercise is another option that might be offered sometime in the future, as it may greatly improve patient outcomes. “Patients with chronic kidney disease (CKD) are typically physically inactive and have self-reported reduced physical functioning,” wrote Matthew D. Beekley, PhD, in Medscape Nephrology.4 “As in the healthy population, reduced physical functioning and inactivity are associated with increased mortality and poor quality of life. Thus, it is not surprising that preliminary reports suggest that for patients with CKD, sedentary behavior is associated with increased mortality.”
And, Beekley added, exercise can help with CKD-associated diseases. Because peak oxygen uptake can help predict survival in ESRD patients, improving that element by adding exercise to the mix can only do good for the patient. “It is well known that patients with CKD have profound muscle wasting, which can result in loss of physical capacity and daily function,” he said. “Resistance exercise, even on a low-protein diet, has been shown to build muscle and strength in the CKD population. It is thus likely that both cardiovascular and resistance exercise can help reduce morbidity and mortality, as well as improve quality of life, in patients with CKD.”
The many services at the clinic are offered à la carte to the patient’s physicians. “The clinic is run by nurse practitioners with medical director oversight by me, and we allow our referring nephrologists to select from a menu of services provided,” Campbell affirmed. “The core services are anemia management, hypertension, secondary hyperparathyroidism issues, lipid management, access placement and education. Along with that, we work closely with the Kirklin Clinic dietitians and do some dietary counseling for renal diets, or for phosphorus restriction, and also make sure our diabetics have gotten their diabetes education and the dietary support they need. We have not started any type of exercise program, although that’s something we’re interested in.”
She acknowledged the benefits of exercise, and noted that there are multiple ways to introduce it into the patient’s lifestyle. “I think there are some people who have used simple exercise prescriptions and they just give the people instructions as to what to do. The opposite end of that spectrum is the supervised exercise you get when you do a cardiac rehab type of program,” she said.
“One of the goals I have for the clinic is to have it be as much of a one-stop shop for the patient as possible, so the patient doesn’t have to get shuttled all over the place. Unfortunately, we don’t have a workout facility in our clinic, but it would be great.”
The clinic was founded approximately three-and-a-half years ago; it grew out of the nephrology division’s anemia management program. “Our anemia program not very well organized, and we had grown. When we started, we just told patients, ‘Come up on Tuesday and we’ll check your hemoglobin and get your erythropoietin shot,’ and we had grown out of that. We would have this mass of people show up on Tuesday morning without scheduled appointments. People would have to go the lab, so if the lab was shut down or if there was a machine down, it would take forever. It was not really workable for the nursing staff, physicians or the patients,” Cambell related.
When the clinic was initially founded, the operators started with the goal of giving the anemia program a little more structure. “So we had patients come with appointment times, and began offering point-of-care hemoglobin measurements so we didn’t have to wait on the lab to make our decisions about erythropoietin. We were helping people get in and out faster. The other thing for the physicians was trying to get some feedback as to the efficacy of the erythropoietin therapy. One of my frustrations before was that I did not get very rapid feedback about people’s iron levels, or what their hemoglobins were doing, or if we need to be titrating drug. For the first year or so [of operations], we addressed that, and we worked on blood pressure control. After the first year, we widened our spectrum and added the secondary hyperparathyroidism, and the lipid and access education aspects,” she recalled.
The majority of the patients seen at the CKD clinic are at stage 4 in their disease. However, the clinic also sees a fair number of patients at stage 3, and even some at stage 5 who are not yet on dialysis. “Stage 5 is defined as a glomerular filtration rate (GFR) of less than 15, so we have some people who present very late and are in the process of getting their access done, but who are still relatively asymptomatic. And we have some people who have been followed for a long time, but their GFRs are hanging there and the primary nephrologist has decided not to start dialysis yet,” Campbell explained.
The Kirklin Clinic is part of a multispecialty academic clinic, so the clinic is supported by the division of nephrology. This close association, however, is not without its issues — because of the cozy relationship, the clinic has no clear picture of its profitability or lack thereof. “This year, we are trying to get a better idea of the profitability of the clinic, or not so much the profitability, but if the clinic is breaking even or not without being subsidized by nephrology,” Campbell clarified. “The clinic helps to free up the nephrologist’s time, so it allows them to see acute patients or sicker patients rather than seeing returns, which is an issue. I can’t give you a firm number of how much we’re in the black or in the red. We’re wrapped into the nephrology division; since we’re part of a multispecialty clinic, our financial people are assigned to us by the clinic, and they are the same for the CKD clinic and the nephrology clinic. This year, we’re trying to break it out into a separate cost center so we can track the expenses for that clinic in particular. It will be exciting to see where we are next year at this time.”
The group will meet quarterly to review reports of the clinic’s fiscal health.
Most of the clinic’s patients are billed under CKD, and this counts as a separate office visit than seeing the nephrologist, so it is considered a separate provider encounter. If the patient has nurse practitioner coverage, they’re seen by just the nurse practitioner and are billed under their insurance for a CKD visit and any other complications of CKD they’re experiencing. If they do not have nurse practitioner coverage and need to be seen in the clinic (because not all patients need to be seen by a provider), then they’re seen by a physician.
Many other types of CKD clinics exist. “One of the neat things about working in CKD and talking to other providers is that there are a lot of different models out there,” said Campbell. “I’ve talked to people in the region at academic centers, who are at private offices and receiving some hospital support, and I’ve also talked to people who have university-based CKD clinics as well. There are several different models out there and different ways of approaching it. One of the important things about CKD is that it’s important to look at your area’s needs and to make sure that whatever service you’re providing is filling those needs — the patient population, what they have access to, and what services are already being under different other clinics, to make sure that what you’re doing is important for both the provider and patient.”
Patients are seen every morning of the week, when the clinic is open for a half-day. Typically, 12 patients will be seen in that short time, for a total of 50 to 75 a week. There are approximately 275 patients currently active, and each patient comes in for a blood pressure and anemia check. They may not need to see the nurse practitioner that day, so will just come in to get blood pressure measured by an LPN or RN, then receive their injection and leave. That scenario is not considered a full visit. However, Campbell says, “If the patient isn’t at blood pressure or hemoglobin target, or if they’re having complications, or they’re scheduled to have more of a sit-down talk about secondary hyperparathyroidism, lipids, etc., then they’ll come in to see the nurse practitioner. There is not a charge for an office visit if they don’t see the nurse practitioner, but there is a charge for the injection.”
The Genesis of CKD Clinics
“The perception that medical care for patients with CKD is suboptimal has resonated with several national organizations,” wrote Ajay K. Singh, MB, MRCP (UK), MBA. “In 1997, the National Kidney Foundation (NKF) began focusing on recognition and treatment of CKD.”5
After this deficiency was recognized, multiple medical facilities determined there was a need for clinics that could rectify the problem. “Fundamental to the establishment of a multidisciplinary CKD clinic is the belief that such clinics eliminate barriers that result in delayed referral of patients to a nephrologist, fragmentation of medical care, and limited patient access to the latest advances in the management of kidney disease,” Singh wrote.
“In order for the CKD clinic to succeed, it must be a smoothly run clinical operation that offers value to patients and families. It also needs a well-planned and well-executed business plan,” he added. “In the short term, the establishment of a CKD clinic may increase practice overhead costs, because patients spend more time in the clinic, which in turn reduces the total number of patients that can be seen during a single clinic session ... Although a CKD clinic may actually lose money for a practice in the short term, the long-term benefits justify the means. For example, the CKD clinic can offer the opportunity for a practice to differentiate itself from the standard approach to patient management, which can ultimately result in a greater volume of patients, as well as increased loyalty among existing patients. Screening strategies can identify and increase the pool of patients who require nephrology management.”
There are three economic models for a CKD clinic, Singh explained — one that imitates a competitor’s best practices; one that specializes in one or two niche elements; or one that specifically aims to be different from competitors by offering novel approaches or services.
Regardless, he concluded, “Early recognition of CKD should lead to management strategies that include screening for comorbidities and early treatments such as blood pressure control with ACE inhibitors and ARB agents, and initiation of erythropoietin for anemia.”
1. http://kidney.niddk.nih.gov/kudiseases/pubs/ chronickidneydiseases/
4. http://www.medscape.com/viewarticle/561596 _ 1
5. http://www.medscape.com/viewprogram/1933 _ pnt