How would you improve dialysis care if you had unlimited resources?

What if we could do more frequent dialysis? Would this improve QOL as potentially seen in the original FHN trial or even improve survival as seen in recent longer-term FHN follow-up?

What if we had more resources to support home dialysis? Would increasing nursing and other provider home visits and patient support make the promise of home therapy a reality for more patients?

What if we had more nurses, technicians, dieticians, or social workers in-center? Would you train them to lead intra-dialytic exercises? Give them skills in cognitive behavioral therapy? Teach patients how to eat better or how to cook? What about iPADs with educational or other productive resources for patients sitting idle in their chairs.

CJASN published an article this month calling for studies focusing on how to improve quality of life for our patients rather than debating which dialysis modality might extend life a few months/years longer. They reference an interesting qualitative study of interviews with over 30 Canadian patients, caregivers, and providers investigating potential research areas. The “top 10 research uncertainties” included items such as: enhancing communication between providers and patients; comparing dialysis modalities’ effects of QOL and mortality; addressing symptom (such as itching or fatigue) control and the psychosocial impact of ESRD; and addressing vascular access concerns. The focus on QOL by patients and their caregivers is notable and something that we should embrace.

Dialysis services in the US have an interesting, and it seems rare, quirk. 90% of patients are prescribed a therapy (in-center hemodialysis) that the vast majority of their doctors would not want for themselves. If you haven’t polled your colleagues yet you’ll likely discover they would favor PD or home hemo should they need dialysis themselves. This is a significant gap compared to our current reality.

So what would you do? 

Robert Rope, Nephrology Fellow, Stanford

Self-cannulation

Bill Peckham, the author of the excellent patient advocacy and home dialysis blog: dialysis from the sharp end of the needle has been on dialysis since 1990 and home dialysis since 2001 where self-cannulates using the buttonhole method. Last year he posted a video on Youtube that I only came across today. It shows his technique of needle insertion. I have often wondered how patients manage to cannulate themselves at home and this demonstrates it very nicely. I am full of admiration for my patients.

 

Home Dialysis University

The dates and locations for this year's Home Dialysis University for Fellows have been released. This is a series of courses on home HD and PD aimed at graduating fellows that is sponsored by the ISPD. You can check out the RFN review of the course here and our twitter feed from it here under #HomeDialysisU. The 4 locations are Charlotte, Dallas, Denver and Chicago and they are going to take place once a month from February to May.

The site for the fellows version is here. There is a similar course run for practicing renal physicians although this is starting in just 2 days in New Orleans. The website for the non-fellow's version is here. 

Conference Review: Home Dialysis University

It doesn't take much to get me to take a trip to San Diego so when the opportunity came up to attend this year's Home Dialysis University conference I booked my flight.  Having lived in San Diego for many years prior to moving to the Bay Area I took the opportunity to both check out this great conference and stay and visit with old friends.

The conference (formerly known as Peritoneal Dialysis University) now has significant content going over home hemodialysis therapies with much of this being delivered by Brent Miller who was one of the FHN daily investigators and part of the ongoing FREEDOM study.

The conference registration and up to $350 in hotel and travel are covered for fellows by a grant from the International Society of Peritoneal Dialysis.  The conference and accommodations were at the Westgate Hotel in the Gaslamp district.  Great location and high marks for tasty breakfast, lunch and frequent snacks (all at no additional cost!)

Conference size was small, under 20 people so lots of opportunity to interact with the faculty and other attendees. Also a short conference, one full day and two half days.

John Burkart from Wake Forest gives a great lecture on how PD and HD work in terms of small and other solute clearance and reviews the uses and limitations of Kt/V.  He also gives a very practical lecture on the financial considerations related to home dialysis.  Anjali Saxena (one of my attendings who is the PD director down at the Stanford affiliated Santa Clara Valley Medical Center) covers PD access issues, the challenges that face the long-term PD patient and the infrastructure requirements for starting your own home unit.  Joanne Bargman from Toronto does some great case based discussions surrounding commonly encountered PD issues.

One of the highlights is the hands-on demonstration session were home dialysis RNs actually do a walk through with a PD cycler and a NxStage machine. Very informative.

An area where many fellows unfortunately have limited exposure is the nuances of the dialysis prescription writing for the NxStage system.  Brent Miller gives a really nice talk going over the details of this.  Lots of nice compare and contrast examples to conventional HD to put things in a more familiar context.

At least as of this writing, they haven't announced when the 2013 fellows conferences are going to be held so stay tuned to their website for dates.  In past years they've had sessions in several locations on several different dates so hopefully you'll find something that will fit your schedule.

I again tried my best to keep up a solid twitter feed of interesting points for RFN which you can find here with all the tweets indexed under #HomeDialysisU.

Webinar: FHN Daily Trial and NxStage Freedom Study

The recent publication of the landmark FHN Daily Trial was a step forward in our understanding of dialysis care.

One of the authors, Dr. Brent Miller from Washington University School of Medicine in Saint Louis, is giving a free webinar entitled The Clinical Impact of More Frequent and Home Hemodialysis: Results of the Frequent Hemodialysis Network Daily Trial, the NxStage FREEDOM Study and other data.

It's running Tuesday, April 19th at 12:00 pm ET and Wednesday, April 20th at 1:00 pm ET.

PD University for fellows

I attended a 2-day conference on home dialysis known as "PD University for fellows" sponsored by the International Society for PD (ISPD), Wake Forest University, Baxter and NxStage in Baltimore, MD. This is a free conference for renal fellows taking place 4-5 times every year at different locations. It was one of the best organized and most efficient meetings I have ever attended.

Based on my experience I strongly recommend that every fellow finds the time during their 2nd year to attend one of these PD University conferences. Unfortunately most fellowship programs are incomplete in teaching all (advantages and disadvantages) of renal replacement therapies. This meeting re-emphasizes that RRTs should not compete with one another but rather complement each other in the life span of a patient with ESRD to provide the best possible therapy for the individual patient in the course of their disease at a given time.

The speakers were engaged and compassionate (John Burkhart, Martin Schreiber, Robert Lockridge, Joanne Bargman) but did not seem to be biased towards one or the other dialysis modality. The topics discussed included:

- Importance of modality education and understanding transition
- Reasons to consider PD more often
- Benefits of home HD - Short Daily to Nocturnal
- PD access: Key catheter placement issues, peri-operative care and catheter complications
- Principles of dialysis
- Approach to volume overloaded patient
- DOQI adequacy guidelines (PD/HD), Kt/V discussion, equations, goals and calculations
- Writing the PD prescription: Solute clearance issues interactive session - adequest
- Access issues in Home HD
- Metabolic issues in PD/HHD Patient, Ca and Phosphate related issues
- HD principles applied at home: Kt/V targets, prescription management, water issues, BP
- Non-infectious complications of PD
- The long term PD patient
- Preventing and managing infectious complications of PD/HHD

This is an excellent conference worthwhile your time while you are in training. Hotel costs and flight are covered! Attending before taking renal boards will certainly be helpful to answer most of the questions on dialysis-related topics.

Dialysis billing

Why do we write notes in the chart day after day? Why does the chart even exist? In my mind, the main function of the medical chart (and progress notes) is communication: charting allows physicians (and other members of the health care team) to effectively communicate with one another when face-to-face communication is not possible. In recent years, however, it seems as if charting has taken on a different primary function: that of a medicolegal document. Not only does the medical chart serve as the official log for documenting what was and wasn't done correctly (in the event of a lawsuit), but it also serves an important function in billing--in order for a physician to get reimbursed for a particular service, he or she must formally document that service, typically by using key words or phrases, within the written chart. Failure to do so correctly can result not only in a failure to get paid hard-earned money, but can even result in allegations of billing fraud.

Thus, it's important to know the dialysis billing codes. Despite its central importance, the details of billing weren't really emphasized to me during either my residency or my fellowship training. Here are a few of the important billing codes and important billing issues related to nephrologists, focusing primarily on the relevant "CPT" (or "Current Procedural Terminology") codes for dialysis. If there are any seasoned nephrology vets out there, please feel free to make comments or clarifications, as I'm just personally discovering the coding game:

• Inpatient Dialysis Codes. The main issue to be aware of here is that in order to get reimbursed for supervising a dialysis session, the attending physician must be physically present while the patient is undergoing the dialysis procedure. Seeing the patient beforehand and writing out the prescription is not enough--you have to be present while the patient is hooked up to the machine. I have been advised to write something like, "The patient was seen and examined while on dialysis," as well as being careful that your date & time on the note is consistent with the patient's time on dialysis. Obviously, this applies only to attendings and not to fellows. The standard inpatient hemodialysis code is the "90935". If you see a patient in the morning and then their status changes such that they now require dialysis, you can still get credit for the procedure by billing a "90937" (again, as long as the nephrologist is present for part of the dialysis procedure). A separate set of codes ("90945" for single visit and "90947" for multiple visits) is used for other dialysis procedures such as peritoneal dialysis; I believe this code can also be used for coding CVVHD.

• Outpatient Dialysis Codes. A list of the major outpatient dialysis codes can be found here; they are generally submitted monthly: the main ones for adult dialysis are "90960" (for 4 face-to-face visits per month), "90961" (for 2-3 face-to-face visits per month), and "90962" (for a single face-to-face visit per month). Separate codes exist for patients who are dialyzed for only a few days out of the month, or for supervising home hemodialysis ("90966").
  

The process of nephrology billing is sufficiently complex that the Renal Physicians Association offers full-day "Coding and Billing Seminars" around the country. The discussion above does not even go into the intricacies of billing for individual injectable medications or all the important disease-specific codes (e.g., ICD-9 codes for CKD, hypertension, etc) which are routinely encountered in outpatient clinical practice.