Improving Rural Access to Nephrology Care
Eric Wallace
Division of Nephrology
Only 3% of 4806 hospitals are
ranked in even 1 specialty.
• #46 in Nephrology
• #11 in Rheumatology
• #36 in Urology
Alabama Health Outcomes
•
•
•
•

#45 Overall Rank
#46 Diabetes Rank
#41 Smoking Rank
#47 Obesity Rank
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

• G...
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 ...
Types of Dialysis
• In Center Dialysis (90%)
• Go to a Center 3 times a week for 4 hours a treatment
• 1-2 hour recovery t...
Standard Home Dialysis Delivery
• Patient undergoes training PD for 8 days and
HHD for 6 weeks.
• Begins to Dialyze at hom...
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 Care
Equality in Quality of Care
• of Care
Equality in Access to Care??
• Dialysis facilities in rural areas are less likely to
offer home dialysis than Urban Center...
What does this mean for for the patient?
• Patients in rural areas don’t get put on home
therapies
• Patients on a home th...
Equality in Quality of Care??
• Unfortunately training in Home Modalities in
Fellowship Programs has lagged behind that of...
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 de...
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 uni...
Telehealth’s Potential for Home Dialysis
• Decrease Patient Travel Time
• Eliminate the Need for Small PD centers with
lim...
Exporting Sub-Subspecialty Care
Fabry’s Disease
Fabry’s Disease
• Rare Genetic Disorder 1:40,000 patients
• Manifestations
• End Stage Renal Disease by the age of 40
• Co...
• UAB is a center of experience for this rare
disease and has one of the largest patient
populations in the country
• UAB’...
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 t...
Why Aren’t We Doing This Already?
Regulations and Infrastructure
• Dialysis is very regulated and telehealth visits for
home dialysis are not currently cove...
What is needed to proceed?
• Infrastructure
• Alabama Department of Public Health and the county health departments
• Alabama Partnership for Telehea...
Conclusion
Technology is making our lives
easier.
Why shouldn't this translate into
easier access to care for our
patients...
Questions?
Supporting Slides
Regulations
• Currently using telehealth for the monthly visit for
home dialysis is not permitted.
• Medicare ESRD telehea...
Regulatory Barriers
• Medicare
• This program could start today if there was a
Medicare exception for the Face to Face Vis...
Outcomes Based Clinical Trial
Clinical Measures Must be Equal to the patients
Being Treated In Center
• Hospitalizations
•...
Previous Experience?
• 1.6 million dollars in a Health Innovations Award
given to Susie Lew at Georgetown University.
Not ...
Ideas or Questions?
PERCENTAGE OF PREVALENT PATIENTS ON
PERITONEAL DIALYSIS BY COUNTRY

2000
2003
2006
2009

USRDS 2011 publication
Equality in Access to Care??
• In 1995 20% of patients in rural areas were on
peritoneal dialysis versus 10% on peritoneal...
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. ...
Improving Rural Access to Nephrology - Dr. Wallace
Improving Rural Access to Nephrology - Dr. Wallace
Improving Rural Access to Nephrology - Dr. Wallace
Improving Rural Access to Nephrology - Dr. Wallace
Improving Rural Access to Nephrology - Dr. Wallace
Improving Rural Access to Nephrology - Dr. Wallace
Improving Rural Access to Nephrology - Dr. Wallace
Improving Rural Access to Nephrology - Dr. Wallace
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  • United Health Foundation stats
  • One of these is able to be changed now with the advances of telemedicine
  • When counseling patient’s on dialysis, I tell them the outcomes of the dialysis are the same. So it is about quality of life.
  • Mantra of healthcare systems are the following equal, autonomous and efficient.
  • In order to understand the Equality part of the equation. You have to understand the standard delivery of dialysis care.
  • So what does this look like for alabama,tn, ms. Maps courtesy of craig remington
  • All home dialysis units in AL tn ms with a 20mile straight line radius around it. All of the patients outside of this area drive to these units despite the distance. There are many more that may have chosen home dialysis if they could have had 1) education 2) been offered the therapy and 3) been able to get to the unit.
  • 888 outside of a 20 mile radius of a unit greater than 20. 200 of these patient outside 40mile straight line
  • Alabam is poised in a position to be a leader in this field that would impact the entire country.
  • We have the technology
  • Being aided by the Alabama Partnership for Telehealth
  • Not because it can’t be done.
  • 20% of my patients live at great distances and come either because t
  • Not because outcomes
  • Alabama is not different,
    So this is if you look at the entire population of the united states or alabama. However, is the entire population equal
  • Improving Rural Access to Nephrology - Dr. Wallace

    1. 1. Improving Rural Access to Nephrology Care Eric Wallace Division of Nephrology
    2. 2. Only 3% of 4806 hospitals are ranked in even 1 specialty. • #46 in Nephrology • #11 in Rheumatology • #36 in Urology
    3. 3. Alabama Health Outcomes • • • • #45 Overall Rank #46 Diabetes Rank #41 Smoking Rank #47 Obesity Rank
    4. 4. How can you have one of the best hospitals in the country and the worst outcomes in the same state?
    5. 5. Access to Care
    6. 6. 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
    7. 7. Telemedicine's Potential in Nephrology • Home Dialysis • Delivery of Subsubspecialized Care • Education
    8. 8. Home Dialysis
    9. 9. 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
    10. 10. 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
    11. 11. 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 .
    12. 12. Equality, Autonomy, and Efficiency
    13. 13. Home Dialysis Autonomy • Self Care • Improved Quality of Life • Flexibility of the schedule not that of the Dialysis Unit
    14. 14. Efficiency • Outcomes are equal • $16,315 less expensive per year per patient than hemodialysis Lukowsky et al (2013)
    15. 15. Equality ??? Not for the Rural Population
    16. 16. Equality?
    17. 17. • Equality in Access to Care Equality in Quality of Care • of Care
    18. 18. 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.
    19. 19. 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
    20. 20. Equality in Quality of Care?? • Unfortunately training in Home Modalities in Fellowship Programs has lagged behind that of InCenter Hemodialysis • Since, only 9% of patient nationwide are on home therapies experience remains low after training This leads to poor outcomes in small centers!
    21. 21. Higher Mortality and Rates of Transfer to Hemodialysis
    22. 22. 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.
    23. 23. How Can We Change the Delivery of Care Paradigm to Provide Equal Quality and Access to Care?
    24. 24. • 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.
    25. 25. 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.
    26. 26. Exporting Sub-Subspecialty Care Fabry’s Disease
    27. 27. 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.
    28. 28. • 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.
    29. 29. How Do We Improve Access to Care?
    30. 30. • 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.
    31. 31. Why Aren’t We Doing This Already?
    32. 32. 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.
    33. 33. What is needed to proceed?
    34. 34. • 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.
    35. 35. 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.
    36. 36. Questions?
    37. 37. Supporting Slides
    38. 38. Regulations • 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
    39. 39. 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
    40. 40. Outcomes Based Clinical Trial Clinical Measures Must be Equal to the patients Being Treated In Center • Hospitalizations • Infection Rates • Mortality • Technique Survival • Albumin • Hemoglobins
    41. 41. 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.
    42. 42. Ideas or Questions?
    43. 43. PERCENTAGE OF PREVALENT PATIENTS ON PERITONEAL DIALYSIS BY COUNTRY 2000 2003 2006 2009 USRDS 2011 publication
    44. 44. 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
    45. 45. 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.
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