Presidential Address: The person and the policy
Lynda Szczech, MD (Duke University)
Dr. Szczech is the outgoing president of the NKF. She’s done amazing work with NKF since assuming her presidency in 2010. In her final presidential address, she decide to focus on a number of policy and medical issues that are changing the CKD and ESRD landscape. Naturally, we aren’t the only ones interested in these issues, as elected officials, medicare recipients (both current and future), and dialysis providers are all stakeholders in what happens to the CKD/ESRD environment.
The largest and most important of these issues is funding. Dr. Szczech noted quite accurately that the US debt-to-GDP ratio has increased (worsened) since 1980, and that we are now feeling those effects in the dialysis community. Medicare expenditures have increased steadily since 1997, with 6% of that budget going to ESRD patients (who only make up 0.5-1% of all medicare recipients). As of 2009, about $80,000 goes to providing HD services per person per year, $50,000 for PD services, and $20,000 for transplant patients. Given these issues, it should come as no surprise that cost-cutting measures had to be implemented, affectionately known by many kidney providers as “the bundle”. The bundle has frightened a number of kidney providers, but Dr. Szczech goes into great detail to show that, thus far, it hasn’t had as deleterious effect as some initially thought it would.
Looking at DOPPS data from 8/2010 to 8/2011, the following trends have been noted (and the bundle was started somewhere between these dates):
— s/p kT/V has been similar during this time period
— weekly EPO doses have decreased over this time period
— IV iron use has increased from 57% to 71%
— phosphorous levels havent’ changed
— PTH levels have increased, especially at levels greater than or equal to 300 (though it’s unclear why)
— and both vitamin D IV use and cinacalcet use has remained stable
So there might be some good news in quality indicators after the implementation of the bundle, but of course we’ll need more time to see its full effects.
Dr. Szczech then turned her attention to public awareness. It’s been a problem in the kidney patient population, with only 42% of CKD stage 4 patients even knowing they had kidney disease. The numbers are worse for early CKD patients, with only 7.8% of CKD stage 3 patients. In 2010 only 56.3% of patients who started dialysis actually saw a nephrologist before being started! For sure, more has to be done to increase awareness and organizations like the NKF are taking the lead in doing just that.
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