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Crazy idea or genius? Nephrology Merit Badges

I want to create a series of buttons to give to residents and students to mark achievements in nephrology.

My birthday is coming up, looking at the 1 inch beginner button system

One of the common resident complaints regarding nephrology is that it’s too hard. The nephrologist response to this complaint  is usually to deny the difficulty, because its not hard for the nephrologist. Perhaps that denial is counterproductive, first it’s hard to disrupt a widely held belief that is continually reinforced by the community of medicine, secondly when you deny the difficulty you insult the intelligence of the student struggling with new concepts. Its essentially saying, “Hard? differentiating among the pulmonary renal syndromes is easy, what are you stupid?”

Instead of denying the difficulty we should re-frame the meme. Yes, nephrology is hard and look how cool it is that you mastered these concepts.

Merit badges, or pieces of flare as my fellow interjected, would add levity and encourage residents to tackle deeper concepts.


Potential nephrology merit badges:
  • It’s the heart, no it’s the kidney, no it’s the heart, no it’s the kidney…: diagnose and successfully treat a case of cardiorenal syndrome
  • ABG guru: interpret ABGs showing all four primary acid-base disturbances
  • Quinton: insert a temporary dialysis access to provide emergency dialysis access
  • Tissue is the Issue: perform a renal biopsy
  • Look Closely: correctly interpret a urine microscopy specimen
  • K/DOQI Genius  : use the K/DOQI guidelines to craft a plan of care for a CKD patient
  • RIFLEry: use the rifle criteria to correctly stage a case of AKI
  • RTA (pronounced like Fonzie would RTAAAAAA!): use urinary anion gap and other clues to correctly diagnose and classify an RTA
  • Bud Rose: use free water clearance to draw meaningful conclusions about hypo- or hypernatremia
  • Put on your Helmut (Rennke): be a star in the pathology room
  • Gerry Appel: exceptional management of nephrotic syndrome
  • Ron Falk: diagnose and manage a patient with ANCA-associated vasculitis
  • The Town Schrier: Use FENa, FEUrea and BUN:Cr ratio in a meaningful way to diagnose a subtle case of pre-renal azotemia
  • Mark Halperin: Master of the Cortical Collecting Duct: use the TTKG equation intelligently to help in the management of a patient
  • Wisdom of Solomon: prevent a case of contrast nephropathy
  • Cry me a river: for expertise in the use of high dose diuretics
  • EPA Super Fund Site: use dialysis to correct uremia in AKI
Suggested merit badges from other creative nephrologists:
  • Way to Go KDIGO: use the KDIGO guidelines to do what ever you want to your dialysis patient 
  • Golden Pocket: Forgetting to tighten the cap on the urine that you are bringing back to the lab to spin
Thanks to Steve Rankin and Edgar Lerma
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Calling all nephrologists! If you care about anemia, you have until August 30th

The Centers for Medicare and Medicaid Services has proposed changes in the Quality Incentive Program (QIP) for 2013. The changes specifically involve anemia. The QIP was created to assure that even though the costs of providing dialysis care are born exclusively by the dialysis provider, there are specific quality goals that if not met result in financial penalties. The quality goals currently place are:

  • Percentage of Medicare patients with an average Hemoglobin < 10.0g/dL (Hemoglobin Less Than 10g/dL Measure)
  • Percentage of Medicare patients with an average Hemoglobin > 12.0g/dL (Hemoglobin Greater Than 12g/dL Measure)
  • Percentage of Medicare patients with an average Urea Reduction Ratio (URR) ≥ 65 percent (URR Hemodialysis Adequacy Measure).

Dialysis units that fail to hit the goals perscribed by the quality score receive a reduction in the Medicare payment by 0.5-2%. It should be apparent that the required hemoglobin targets ares problematic, especially given the recent action by the FDA (see my recent post Between a rock and a hard place). CMS is proposing the elimination of the floor on hemoglobin targets:

…Therefore, for the PY 2013 ESRD QIP, we propose to continue to use the following two measures previously adopted for the PY 2012 ESRD QIP:

  • Hemoglobin Greater Than 12g/dL Measure.
  • URR Hemodialysis Adequacy Measure.

This feels wrong to me. Creating an economic incentive that puts the cost of treating anemia on the provider but doesn’t provide any minimal goals may result in a race to the lowest hemoglobin. What’s to stop a rogue dialysis unit from removing ESAs from their formulary. We can all freely admit that ESAs have some previously under appreciated risks and that our enthusiasm for treating anemia was not entirely evidence-based, but our response to should not be to turn back the calendar to 1988.

After the release of Epo, the transfusion rate plummets. It falls by two thirds in a year and continues to fall so that the current rate of 0.3% per quarter represents a 98% reduction in transfusions. Revolutionary. And this doesn’t even begin to address the quality of life brought to dialysis patients by higher hemoglobins.

CMS states that they cannot add another unique quality indicator for 2013 and are looking toward 2014 to do this. In the absence of new quality guidelines they should keep the goal to maintain a hemoglobin over 10 g/dl but lower the target to 9 g/dL for 2013.

Patients deserve an incentive that keeps providers conscious of anemia. In study after study, low hemoglobins walk hand in hand with poor outcomes. The concern regarding anemia has been driven by attempts to normalize hemoglobin. It is clear that normalization is hazardous and without scientific support; however a failure of the experimental group does not mean we should abandon the therapy given to the control group. In every study the control group received ESA to maintain hemoglobins at least 9 g/dL.  Removing the hemoglobin floor from the quality measures would be giving a de facto license to withhold an important medication from dialysis patients.

The TREAT trial is the best study every done on outcomes in CKD with an ESA.
These dosing groups resulted in an effective separation in hgb with little profound anemia

I have copied this post to Regulations.gov as my comment on the latest guidelines.

The deadline for comments is August 30th.

A science liaison at Amgen told me that Amgen was advocating for a hemoglobin floor of 10 g/dl. The Renal Physician Association is also supporting a hemoglobin of 10 g/dL. [This paragraph was updated 8/22/11, after a complaint that I mis-interpreted Amgen’s position. My apologies.]

I have heard that CMS has received few comments from physicians. Embarrassing. Anemia is important and nephrologists should care how the governments crafts incentives that will change how our patients are treated. Go now and comment. Tell CMS what you think.

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Great article on the Nesiritide debacle

There has been some great articles regarding the expensive, waste of a decade induced by nesiritide.

I like this article the most because it’s written by someone who is not in medicine. It tackles many of the same issues I looked at in my post, The problems with numbers, namely when drugs are approved based on intermediate end-points bad things can happen.

The best thing we can say about niseritide is that when the definitive trial was finally done, the previous concerns about renal failure, were shown to be merely illusions created by the smoke and mirrors of meta-analysis.

Acute renal failure was an early concern regarding Nesiritide…

…but when the right placebo controlled trial was done, no renal failure.
So go and read Carolyn Thomas’ view of nesiritide and see how we have failed the people we are entrusted to care for.
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Davita: is the vial half empty or half full

Early Tuesday, I caught half a headline about drugs being wasted at the expense of Medicare and to the benefit of some dialysis company. A few hours later I saw the first caustic tweets:

Just some of the angry tweets

Then I started getting direct messages asking for my thoughts. Recently, Davita has been getting more than its share of bad press recently and this seemed like more of the same. The facts of the news story, as far as I can tell, are as follows

  • A former medical director and nurse brought a whistle blower suit against Davita
  • They accuse Davita of using large vials to administer IV drugs during dialysis. The large vials resulted in excess medication being wasted
  • Medicare pays for the entire vial regardless of how much is wasted
  • The Justice department investigated this claim for more than two years and decided not to join the lawsuit
My first reaction was Davita had done a bad, bad deed here but the more I thought about it, the more that seemed to be a rush to judgment. The fact that the Justice Department, after investigating  for two years, did not join the lawsuit became the itch I could not ignore. My interpretation, is that the Feds looked into how Davita was handling the drugs and they did not find any unlawful activity.

So I was satisfied with the assumption that the way Davita was handling the drugs was legal. However, even when things are within the letter of the law we want our medical institutions to use resources efficiently. Clearly, intensionally pouring drugs down the biohazard drain, as the whistle blowers contend, is not the most efficient use of medical resources. The problem was the Medicare reimbursement system. For years, Medicare underpaid for the dialysis procedure so that dialysis providers had to turn themselves into high-end retail pharmacies that peddled Epo, and Zemplar in order to keep the lights on. With this type of system the providers were incentivized to use as much drug as possible. This perversion of fee-for-service has been at the root of almost all of the recent scandals in dialysis units. The recent anemia controversies were driven to the forefront largely because dialysis companies were payed for giving drugs not for patient oriented outcomes.

Its clear to me that retail pharmacy system was not the system we wanted. The laws need to change and you know what? This system is no longer the law. Bundling began earlier this year and removes these perverted incentives in order to better align provider and patient goals. In response to the new incentives you know what happened? The vials became right sized and Epo use plummeted. It’s too early to see how bundling effects patient outcomes but Davita and the other Large Dialysis Organizations are responding to the new incentives.

The lesson here is that incentives drive medical decision making. Incentives need to be implemented thoughtfully because small, seemingly minor holes can be blown wide open and introduce major distortions in the delivery of care. In terms of this whistle blower case, I think we shouldn’t dwell on the cows leaving the old barn that has been replaced by one with automatic and secure doors. The old reimbursement system was broken and has been fixed (or at least changed) and I don’t think there is much to be gained by dwelling on the previous system’s inefficiencies and errors.

So as I see it:
  • Davita administered and wasted dialysis drugs in a way that is uncomfortable, and inefficient but legal.
  • The Government realized the incentives were not aligned with better outcomes and changed the incentives
  • Davita and the other large dialysis organizations have changed their purchasing and administration procedures in response to the new incentives
  • A couple of former employees want to sue Davita for its legal, but opportunistic, drug handling behavior under the old incentives
Transparency: I am a part owner of a dialysis joint venture with Davita and one of my partners, Robert Provenzano, is Davita’s VP of Medical Affairs.
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Safari’s Reader function in Lion

I upgraded to Lion on my MacBook Air last week and I’m using Safari in full screen mode. One of the side-effects of this is that many text based sites are too wide for comfortable reading.

Clicking “Reader” in the address bar (or command-shift-R) drops a shadow across the page and opens an overlay containing the core text of the page minus annoying ads and other visual distractions. Really nice.

Click here
and see this uncluttered clean version of the text

The reader feature was introduced with Safari 5 as part of Snow Leopard but it wasn’t until I started living in full-screen mode that the utility of this feature presented itself.