Improving Rural Access to Nephrology CareEric WallaceDivision of Nephrology

Only 3% of 4806 hospitals are ranked in even 1 specialty.

•#46 in Nephrology

•#11 in Rheumatology

•#36 in Urology

• #45 Overall Rank

• #46 Diabetes Rank

• #41 Smoking Rank

• #47 Obesity Rank

Alabama Health Outcomes

How can you have one of the best hospitals in the country and the worst outcomes in the same state?

Access to Care

Barriers to Access to Care

• Economic Barriers• Insurance

• Co-pays

• Communication Barriers• Language of Medicine

• Geographic Barriers• Distance to drive to get to healthcare

• Lack of Adequate Transportation

• Money for Gas

Telemedicine's Potential in Nephrology

•Home Dialysis •Delivery of Subsubspecialized Care

•Education

Home Dialysis

Renal Replacement Therapy

• In 2011, Medicare spent 34.3 Billion dollars on the care of 507,000 dialysis patients

• Renal replacement therapy is needed when a patient’s own kidney is unable to meet the demands of the body.

• Currently there are 2 ways with which to replace the function of the kidney• Transplantation

• Dialysis

Types of Dialysis

• In Center Dialysis (90%)• Go to a Center 3 times a week for 4 hours a treatment

• 1-2 hour recovery time

• Home Dialysis (10%) • Home Hemodialysis (1%)

• Peritoneal Dialysis (9%)• At home

• 7 day a week therapy but done while the patient sleeps

Standard Home Dialysis Delivery• Patient undergoes training PD for 8 days and

HHD for 6 weeks.

• Begins to Dialyze at home

• Then the patient has a mandated monthly face to face visit .

Equality, Autonomy, and Efficiency

Home Dialysis

Autonomy• Self Care

• Improved Quality of Life

• Flexibility of the schedule not that of the Dialysis Unit

Efficiency• Outcomes are equal

• $16,315 less expensive per year per patient than hemodialysis

Lukowsky et al (2013)

Equality ???

Not for the Rural Population

Equality?

• Equality in Access to CareEquality in Quality of Care

Equality in Access to Care??

• Dialysis facilities in rural areas are less likely to offer home dialysis than Urban Centers?

• Geographic barriers to home dialysis in that peritoneal dialysis centers are located in urban areas.

What does this mean for for the patient?

• Patients in rural areas don’t get put on home therapies

• Patients on a home therapy in rural areas sought out home therapies in urban areas

• Then once they are on the therapy they must travel once monthly to a center

• Places an undue hardship on patients who wish to care for themselves in their home to do a home therapy

Equality in Quality of Care??

•Unfortunately training in Home Modalities in Fellowship Programs has lagged behind that of In-Center Hemodialysis

•Since, only 9% of patient nationwide are on home therapies experience remains low after training

This leads to poor outcomes in small centers!

Higher Mortality and Rates of Transfer to Hemodialysis

Summary

Autonomy- Home Dialysis increases patient autonomy as it is self-care

Efficiency- Less Expensive Modality which delivers as good of care with better patient satisfaction.

Equality- Home dialysis is not Equal in Quality or Access to Care in Rural Alabama due to the distances required for patient travel and lack of physician expertise in these areas.

How Can We Change the Delivery of Care Paradigm to Provide Equal Quality and Access to Care?

• Option 1: Build a lot of small home dialysis centers in rural areas. • Alabama- 23 more units

• Mississippi- 29 more units

• Tennessee- 16 more units

• Option 2: Eliminate the Monthly Face to Face visit.

• Option 3: Allow centers with expertise to reach out to rural areas using telehealth, expanding access to care.

Telehealth’s Potential for Home Dialysis

• Decrease Patient Travel Time

• Eliminate the Need for Small PD centers with limited expertise in Home Dialysis

• Improve Access to Care

• Improve Patient Autonomy

• Improve Patient Choice of Physician

• Increase Efficiency• If Alabama could increase from 10% to 20% PD. There

would be a savings of $12 Million per year.

Exporting Sub-Subspecialty CareFabry’s Disease

Fabry’s Disease

• Rare Genetic Disorder 1:40,000 patients

• Manifestations• End Stage Renal Disease by the age of 40

• Congestive Heart Failure

• Stroke

• Neuropathy

• Requires sub subspecialized care by people who understand this rare disease.

• UAB is a center of experience for this rare disease and has one of the largest patient populations in the country

• UAB’s Fabry’s clinic evaluates patients from Georgia, Florida, Mississippi, and Kentucky

• Once a patient is identified, family screening is necessary and those patients identified with the mutation then need to be evaluated.

How Do We Improve Access to Care?

• Option 1: Care of the disease done by the patient’s local geneticist, cardiologist, or nephrologist• The treatment of this disease costs $300,000 per

patient per year.

• Very difficult decision to decide who needs treatment and more difficult now to decide who does not.

• Option 2: Telehealth visits in the evaluation and follow up for these patients.

Why Aren’t We Doing This Already?

Regulations and Infrastructure

• Dialysis is very regulated and telehealth visits for home dialysis are not currently covered by medicare.

• Blue Cross/ Blue Shield Currently does not cover any telehealth

• Fabry’s visits would be covered by existing guidelines but there is currently limited telehealth infrastructure in Alabama. • This infrastructure could not be built based on the needs

of so few patients.

What is needed to proceed?

• Infrastructure• Alabama Department of Public Health and the county health departments

• Alabama Partnership for Telehealth

• UAB satellite clinics

• Lists of Statewide health resources available

• Infusion Centers

• Outpatient Labs

• Radiology

• Regulatory• Private payers such as Blue Cross/Blue Shield should reimburse these

visits.

• Designated rural areas should have the easiest access to telemedicine

• For sub sub specialized care such as Fabry's crossing of state lines needs to be addressed with a National Medical License.

Conclusion

Technology is making our lives easier.

Why shouldn't this translate into easier access to care for our patients?

Telemedicine holds the key to transforming delivery of care, not just in nephrology.

Alabama along with UAB has the potential to lead and NEED to lead to improve health outcomes.

Questions?

Supporting Slides

• Currently using telehealth for the monthly visit for home dialysis is not permitted. • Medicare ESRD telehealth coverage

90951,90952,90954,90955,90957,90958,90960,90961

• Not 90966- Home dialysis MCP

Regulations

Regulatory Barriers

• Medicare

• This program could start today if there was a Medicare exception for the Face to Face Visit• Currently exceptions are granted on a case by case

basis

• And as such, protocolization of these visits in this manner cannot currently be done

• Could be done as a clinical study and will need minimal grant funding to start the program

Outcomes Based Clinical Trial

Clinical Measures Must be Equal to the patients Being Treated In Center

• Hospitalizations

• Infection Rates

• Mortality

• Technique Survival

• Albumin

• Hemoglobins

Previous Experience?

• 1.6 million dollars in a Health Innovations Award given to Susie Lew at Georgetown University. Not to replace the Face to face visit (this is still required) but to add more visits.

Ideas or Questions?

PERCENTAGE OF PREVALENT PATIENTS ON PERITONEAL DIALYSIS BY COUNTRY

USRDS 2011 publication

2000200320062009

Equality in Access to Care??

• In 1995 20% of patients in rural areas were on peritoneal dialysis versus 10% on peritoneal dialysis living in urban areas.

• Today in AL, MS, and TN the prevalent home dialysis patient is equal whether you live in a rural area or an urban area

PD and HD with AVF or Graft

HD with a CVC

Perl, J., Wald, R., McFarlane, P., Bargman, J. M., Vonesh, E., Na, Y., et al. (2011). Hemodialysis Vascular Access Modifies the Association between Dialysis Modality and Survival.