The Nephrology Interdisciplinary Team: An Education Synergism Jane S. Davis and Kim Zuber Patients with kidney disease often have a poor understanding of their condition. The interdisciplinary team can effectively educate these patients to slow disease progression and enhance self-management. The kidney community needs large, well-designed studies to determine the best way to educate patients and hopefully stem the tide of a rapidly increasing population of kidney patients. Congress authorized payment to eligible providers for kidney disease education for Medicare beneficiaries. However, this benefit is not being optimally used. In addition, reimbursement denials were 14-17% in 2011 and 20-23% in 2012. This is more than 4 times the usual Medicare denial rate for current procedural terminology (CPT) codes. Q 2014 by the National Kidney Foundation, Inc. All rights reserved. Key Words: Nurse practitioner, Physician assistant, MIPPA, Education
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hen professionals gather, there is often the exchange of stories of times when patients' questions took us off guard. Often, we thought we had prepared our patients and their families by educating them on the disease process and their own progress. Then, a question comes out of the blue and makes us question what we have been missing. The following are just 3 of the many quotes that the authors have personally heard from patients. Each directed us to re-examine our approach. As we have shared them with others, we have found we were not unique: Other practitioners have had similar experiences and were likewise taken aback. “I know I have a touch of kidney disease.” This was spoken by a 68-year-old African-American female who smokes and is an overweight type II diabetic, is sedentary, and has an estimated glomerular filtration rate (eGFR) of 24 mL/minute/1.73 m2. “I want to donate my kidneys. Who do I call?” This question was asked to an advanced practitioner (AP) by a dialysis patient. “Oh, I have kidney disease?” This question was asked by a Stage 4 CKD 75-year-old patient who has been followed by nephrology for 11 years. These are real questions posed by real patients. Unfortunately, these are not isolated incidents.
The Scope of the Problem The nephrology community recognizes that CKD is approaching epidemic proportions. Data from 2010 show that 116,946 patients initiated renal replacement therapy (RRT) in the United States.1 Annual costs for hemodialysis (HD) and peritoneal dialysis (PD) in this country exceed From the Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL; and Metropolitan Nephrology, Alexandria, VA. Financial Disclosure: The authors declare that they have no relevant financial interests. Address correspondence to Jane S. Davis, DNP, Department of Nephrology, University of Alabama at Birmingham, 3605 Oakdale Road, Birmingham, AL 35223. E-mail: [email protected] Ó 2014 by the National Kidney Foundation, Inc. All rights reserved. 1548-5595/$36.00 http://dx.doi.org/10.1053/j.ackd.2014.03.013
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$47.5 billion annually. In 2010, the National Kidney Foundation (NKF) estimated there were 26 million people with CKD and 8 million in Stage 3 or 4.2 The value of early referral to nephrology has long been known. Patients who are referred when their disease is well advanced reach end stage more rapidly, have increased incidence of associated conditions such as anemia and cardiovascular complications, are more prone to initiate dialysis with a catheter, have an increased hospitalization rate, and have poorer survival rates.3 The specter of an oncoming tide of kidney patients is not confined to the United States. The same prospects of an increasing number of patients with kidney disease are found in the United Kingdom.4 In Australia, between 7.5% and 11.4% of the population is estimated to have reduced kidney function.5 Awareness comes through education, and it takes a team to educate the patients and empower them to be active participants in their own care. The result can be a synergism of the parts. Patients who are informed and have the knowledge to participate are often are more likely to adhere to the care plan, have better outcomes, and are wiser users of healthcare resources.6 The composition of the health-care team (interdisciplinary team [IDT]) depends on the resources available. Ideally, it includes a nephrologist, AP, registered nurse (RN), renal dietitian (RD), social worker, pharmacist, and patient volunteers. Team members and their contributions to patient education vary widely based on resources and availability. The IDT is not a new concept. It has been promoted since the early 1990s. In fact, using the IDT for patient care is required in the Conditions of Coverage in the dialysis units.7 However, there have been few large-scale studies to support its use in the CKD clinic. One model kidney disease education (KDE) program, the Missouri Kidney Program initiated patient education in 1984. The 6 sessions were led by a renal social worker and the individual sessions were led by a social worker, RD, or RN. Topics included modality education, nutrition, and financial issues that patients face.8 Mendelssohn suggests 2 main reasons that the team is not more widely used.3 The first barrier he suggests is nephrologists' attitudes. The second is a lack of resources. Until IDTs can demonstrate a financial advantage in the clinical setting, their use will be limited. On the basis of
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limited evidence, Mendelssohn predicts that the team will choice and that dialysis has less of an effect on their lives prove its worth as a cost-effective measure by delaying than their HD counterparts.13 A 2003 study of ESRD patients' decision-making showed that although 41.5% of initiation of renal replacement therapy (RRT) and the patients wanted shared decision-making, 48.4% increasing the number of patients initiating RRT with a believed that decisions were being made for them without permanent access, choosing more home modalities and their input.6 requiring fewer hospitalizations. He contends that the Addressing these needs is a task for the entire team. The study of the economics of CKD is fairly new and it will roles of the nephrologist, AP, and RN are self-explanatory. take time and study to determine the dollar value of The other team members contribute by adding their experteam intervention.3 Education is the right thing to do for patients to protise to individualize care for the patients and their families. vide good care, and it has economic benefits. Patient edIn this case, the budget and resources are the limits, not the ucation has been associated with all of the benefits sky. suggested by Mendelsohn.3 The demographics speak Although the practitioner is the best resource for managfor themselves. Although the U.S. population with Stage ing and explaining the disease process, the RD can provide 4 CKD is less than 1%, the numbers have greatly 1-on-1 nutritional education and help the patient incorpoincreased over the last 20 years and the largest increase rate the dietary restrictions imposed by kidney disease into is in the patients over 65 years old.9 Education can often their lives. The social worker is invaluable for identifying delay the onset of dialysis, increase the use of home financial needs and accessing resources. If available, a therapies, and improve overall outcomes; however, papharmacist is valuable in educating patients regarding tients often report dissatisfaction with the information the multiple medications that most are prescribed. The they receive or a lack of knowledge of their disease pharmacist also serves as a staff resource regarding drug and options.9 Twenty-six million people in the United dosing, drug interactions, and new products. States have CKD, and nearly 1/3, or 8 million, are in The role of the patient volunteer is relatively unexplored. the late stages.10 It has been 1 of the author's What patients need to know experience that patients and what is important to often relate well to other paCLINICAL SUMMARY them varies with their stage. tients, and talking to someIn the early stages (1-3A), one who has “been there, Kidney disease is approaching epidemic proportions the focus needs to be on disdone that” is beneficial worldwide. ease management to prevent and reassuring. One finding Early referral to nephrology and education have or delay progression. In the showed that patients discuss demonstrated improved patient outcomes. later stages (3B-4), education more personal issues, The team approach to patient care is likely effective, but is more intense and should including how a condition aflarge scale studies are lacking. focus on medication, nutrifects one's daily life and tion, lifestyle, and financial coping strategies.14 MIPPA provides reimbursement for Medicare Stage 4 CKD The team approach is management as well as RRT patients, but is an under-utilized benefit. consistent with the emphasis modalities. It is in these on patient-centered care stages that involving all with the focus on shared available members of the decision-making and patient team is most beneficial. choice. The providers share with patients the information Patients rank knowledge of kidney disease, treatment for them to make their own decisions.15 This establishes a options, access care, and medication compliance as their partnership between the health-care providers and the pamost pressing issues. Maintaining social relationships tient as opposed to the former model in which the provider and activities is a prime concern for patients for when dictates the plan of care. The focus shifts from talking at the they initiate RRT. Kidney practitioners are well versed in patient to talking with the patient.1 symptom management. However, they may not always 2 recognize what the patient wants and needs to know. A Education report investigating the CKD awareness of U.S. adults In addition to a lack of familiarity with using the IDT showed that despite the increased numbers of patients with CKD, awareness remained low. The report also noted approach and the financial considerations, research in usthe same prevalence of CKD among Caucasians and Afriing teams for predialysis education is sorely lacking. The studies are often small, and practices vary in different can Americans, although there are 4 times as many African countries that have different medical models. Strand and Americans with ESRD. A 3rd finding was that the increased numbers of ESRD patients might be a result of Parker conducted an extensive literature review of studies comparing the IDT and the traditional model and the effect improved survival and earlier recognition of CKD.11 The American Association of Kidney Patients surveyed ESRD on patient outcomes. Initially, 927 articles published bepatients from their database and found that although tween 1990 and 2009 were considered; after evaluation, 4 nearly 70% reported receiving education about in-center met the criteria. Outcome measurements included laboraHD, only 58% reported being told of PD and 31% of tory values, blood pressure, time to dialysis, and quality of home HD.12 This is particularly concerning in that PD palife. Two of these were randomized control trials (RCTs) tients have reported increased satisfaction with modality and 2 were observational studies. Although the end points
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varied, 3 of the 4 showed positive outcomes with better blood pressure and diabetic control and 2 demonstrated delay to RRT initiation.5 One trial did not result in differences between the study and control group; instead, it showed the study population had an increased use of services.16 It should be noted that in this study the patients were seen in nephrology but were managed by their primary providers and the nephrology providers sent recommendations for their care. The authors concluded that although the IDT appears to have positive effects on patient outcomes, more well-designed RCTs are needed to support this indication.5 Another review that supported this indication studied RCTs that evaluated educational interventions with patients in early and late stages of CKD as well as dialysis patients. They found 22 reports that evaluated educational interventions, but most focused on diet and/or fluid compliance in dialysis patients. Only 1 was long term (20 years) on increased survival rates with a predialysis intervention. Overall, they found the studies to be of poor quality because of small sample sizes, inadequate reporting, and inconsistency in the interventions. Their review found positive outcomes from predialysis education despite the low numbers and quality of the study. The positive message is that the opportunity to make a meaningful intervention for patients exists.17 The future of CKD education is a mixture of good news and bad news. The good news is that the tools are available. There are multiple resources for patient and provider education. These are often provided at no cost or very low cost; they cover a wide range of topics; they come in languages other than English; and they include written, web-based, and video presentations. There are also provider resources with lesson plans, practice tool kits, and tracking programs.18 The bad news is that there are many tools available. The busy practitioner does not always have the time to sort through the many resources and evaluate the available information. Practitioners are not always well schooled in health literacy, and what makes perfect sense to a professional is often misunderstood by the patient. It is often difficult to find the resources that best apply to a particular patient population. The practitioner can begin with resources such as those available from the NKF Kidney Learning Systems and from the Medical Education Institute's Life Options. In addition, NKF and Life Options offer Power Point patient education programs.18 Recognition of health literacy is a relatively new issue. It is only in the last 20 years or so that it has been a topic of discussion. Populations with low health literacy have a higher number of morbidities and thus a higher use of health resources. Populations at risk include those who are older, have low education levels, and lower incomes. These are many of the same people at risk for CKD. Estimates are that 90 million people in the United States have basic or below-literacy skills and a greater number (110 million) lack basic mathematical skills. Health literacy is more than understanding a written statement; it is essential that the person be able to communicate with providers to make decisions.19 Complicating the issue is the lack of data. There have been studies in cardiology and endocrinology demonstrating the
value of improved patient conditions when health literacy issues were addressed. However, there are scant data on CKD patients' health literacy and very little on dialysis patients. Estimates are that up to 50% of patients on dialysis have limited health literacy, which is associated with poor blood pressure control, missed dialysis treatments, and increased emergency department use.20 Assessing a patient's health literacy is difficult. Although several tools exist, few are specific to the CKD population. Gordon and Wolf applied the Rapid Estimate of Adult Literacy in Medicine-Transplantation tool to 124 kidney transplant recipients. They found that although 91% of the kidney transplant recipients studied had adequate health literacy, many (81%) were unfamiliar with at least one term related to kidney transplant.21 Developing a practical health literacy tool is a challenge, but it must be pursued.
Patient Education As practitioners struggle with providing the right information to their patients and slowing disease progression, the patients struggle with understanding what is expected of them and incorporating changes into their lives. These changes often involve altering lifelong habits. Think of the Stage 4 CKD patient who has received extensive dietary instruction regarding salt, phosphorus, and potassium restriction. This patient attends an annual family reunion and is faced with a table groaning with fried chicken, macaroni and cheese, sausage biscuits, potato salad, watermelon, and homemade chocolate ice cream. Imagine the same patient's dilemma when friends at work plan a pizza party. In addition, the patient has been given a medication list that includes 1 tablet taken twice a day with food, 1 taken with every meal, 1 taken once a month, 1 taken at bedtime, and 1 taken in the morning and early afternoon. Is it any wonder there is confusion? The patient is confronted with a flood of information during a 15-minute clinic visit. Bicarbonate level, potassium, phosphorus, hemoglobin, iron, parathyroid level, and glomerular filtration rate—all of these are foreign to most patients, and after the visit, most would be hard pressed to explain what was important and why.
Medicare Improvements for Patients and Providers Act A major breakthrough occurred in April 2008, when the Medicare Improvements for Patients and Providers Act (MIPPA) authorized eligible providers (physicians, physician assistants, nurse practitioners, or clinical nurse specialists) to bill Medicare under their own National Provider Identifier number for KDE. Medicare beneficiaries with Stage 4 CKD are now eligible for 6 lifetime hours of KDE. In promoting this benefit, interested parties, including the Renal Physicians Association, the NKF, and the American Association of Kidney Patients, promoted early education to improve patient outcomes. These improvements were hoped to slow the patients' kidney function decline, to have modality education leading to initiation of RRT with a functional permanent access,10 and to increase kidney transplantation rates.21 Requirements for the classes are detailed in the Federal Register.22
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Table 1. Breakdown of Instructors and Sites by Year for Kidney Disease Education Classes by Group (G0421)
Class Site Office Nephrologists PA and NP General Medicine Hospital Medicine Total Office Outpatient Hospital Nephrologists PA and NP General Medicine Hospital Medicine Other (Lab, Dietitians) Total Outpatient Hospital Dialysis Unit Nephrologists PA and NP General Medicine Hospital Medicine Total Dialysis Unit Custodial Care Nephrologists PA and NP General Medicine Hospital Medicine Total Custodial Care Not Specified Nephrologists PA and NP General Medicine Hospital Medicine Total Not Specified Total Classes
2010
2010
2011
2011
2012
2012
Number of Classes
Percentage of Classes
Number of Classes
Percentage of Classes
Number of Classes
Percentage of Classes
407 938 25 0 1370
30 68 2 0
617 1343 30 0 1990
31 67 2 0
288 1124 46 0 1458
20 77 3 0
80 143 0 0 2 225
35 64 0 0 1
244 100 7 0 0 351
69 29 2 0 0
81 43 1 0 0 125
65 34 1 0 0
17 0 0 0 17
100 0 0 0
0 0 1 0 1
0 0 100 0
0 0 0 0 0
0 0 0 0
0 0 0 0 0
0 0 0 0
5 0 0 0 5
100 0 0 0
0 0 0 0 0
0 0 0 0
0 0 0 0 0 1612
0 0 0 0
35 4 4 0 43 2390
81 10 10 0
1 8 0 0 9 1592
11 89 0 0
Abbreviations: NP, nurse practitioner/clinical nurse specialist; PA, physician assistant. The total number of classes in 2010 ¼ 1612, in 2011 ¼ 2390, and in 2012 ¼ 1592.
The specifications set out in the Federal Register are at once specific and vague. A post-test is required, and the class content must be tailored to patients' individual needs. The test questions and methods of assessing those needs are left to the practitioner. Although MIPPA only authorizes reimbursement for providers with an National Provider Identifier, it does not exclude other members of the IDT from participating, nor does it state what percentage of each session must be led by the practitioner. This gives each practice leeway in offering the best education it can provide to its patients.23 KDE classes have been offered nationwide since 2010. Previous reports have found that most groups offer 2 classes/patient and are available to all CKD patients regardless of insurance.21 A review of the data from the KDE billing as released by the Centers for Medicare and Medicaid Services (CMS) showed trends that continue into 2012.22 Using the Public Use File that is released by CMS, all billed/paid KDE classes for 2010, 2011, and 2012 were reviewed. APs continue to dominate as the group class instructors in 2012 as they did in 2010 and 2011 (67%, 61%, and 74%, respectively) (Table 1). For individual clas-
ses, nephrologists are the dominant instructors for 2010, 2011, and 2012 (56%, 55%, and 47%, respectively). However, the percentage of individual classes taught by APs has grown from 2010 through 2012 (29%, 31%, and 34%, respectively) with classes taught in the home dominated by APs (Table 2). Although nephrologists have not participated in the teaching of home KDE classes, this site has increased by the largest percentage each year. There were 48 home classes in 2010, 283 in 2011, and 1336 in 2012 for a growth rate of 90% and 64%, respectively. Since the KDE class can be billed on the same day as an evaluation and management visit, the use of KDE for a longer counseling and education class for the CKD Stage 4 patient is an important armament for the home practitioner. Although the entire nephrology community fought for KDE classes, a worrisome trend is developing. KDE was authorized for billing in 2010, but because of a computer glitch, only 9 months of 2010 were billable.24 Thus, a large growth in billable classes from 2010 to 2011 was expected. This occurred in individual classes and group classes (16% and 33%, respectively). However, the growth in KDE classes is less evident from 2011 to 2012. Although there was
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Table 2. Breakdown of Instructors and Sites by Year for Kidney Disease Education Classes by Individual (G0420)
Class Site Office Nephrologists PA and NP General Medicine Hospital Medicine Total Office Home Nephrologists PA and NP General Medicine Hospital Medicine Total Home Inpatient Hospital Nephrologists PA and NP General Medicine Hospital Medicine Total Inpatient Hospital Outpatient Hospital Nephrologists PA and NP General Medicine Hospital Medicine Total Outpatient Hospital Dialysis Unit Nephrologists PA and NP General Medicine Hospital Medicine Total Dialysis Unit Nursing Home Nephrologists PA and NP General Medicine Hospital Medicine Total Nursing Home Total Classes
2010
2010
2011
2011
2012
2012
Number of Classes
Percentage of Classes
Number of Classes
Percentage of Classes
Number of Classes
Percentage of Classes
2522 1286 566 4 4378
58 30 12 ,1
3131 1458 500 3 5092
61 29 10 ,1
2991 1454 524 3 4972
60 29 10 1
0 9 37 2 48
0 19 77 4
0 152 302 29 483
0 32 62 6
0 604 615 117 1336
0 45 46 9
10 5 7 0 22
45 23 32 0
0 1 0 0 1
0 100 0 0
1 0 0 0 1
100 0 0 0
5 117 0 0 122
4 96 0 0
10 140 18 0 168
6 83 11 0
32 113 0 0 145
22 78 0 0
9 0 1 0 10
90 0 10 0
3 0 0 0 3
100 0 0 0
17 2 9 0 28
61 7 32 0
0 0 0 0 0 4580
0 0 0 0
2 0 12 0 14 5761
14 0 86 0
0 0 0 0 0 6472
0 0 0 0
Abbreviations: NP, nurse practitioner/clinical nurse specialist; PA, physician assistant. The total number of classes in 2010 ¼ 4580, in 2011 ¼ 5761, and in 2012 ¼ 6472. General Medicine includes general practitioners, family practitioners, internists, neurologists, and gerontologists. Hospital medicine includes hospitalists, surgeons, physiatrists, emergency medicine, laboratory (2010 only), dietitians (2010 only), and obstetricians/gynecologists (2012 only).
an increase in the number of individual classes (5761 in 2011 to 6472 in 2012 for a growth rate of 16%), there was a loss of group classes (2390 in 2011 and 1592 in 2012 for a 50% loss) (Fig. 1). Adding all KDE classes together for 2010 to 2012, a disturbing trend is seen: although there was a 20% growth in KDE classes from 2010 to 2011 (6462 and 8151, respectively), there was actually a 1% loss in the number of classes from 2011 to 2012 (8151 and 8064, respectively). This decrease in KDE classes appears not to be because fewer classes were taught or billed but it is instead directly tied to an increase in the number of classes being denied by the CMS Medicare contractors (Fig. 2). In 2010, the denial rate for KDE classes was 1% for individual and group classes with denials for dietitian, labs and other nonauthorized KDE instructors. The 2011 denial rate was 14% and 17% for
Figure 1. Total numbers of kidney disease education (KDE) by year. KDE classes for years 2010, 2011, and 2012 by individual (G0420) and group (G0421) are shown.
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Figure 2. AMA 2013 National Report Card Comparisons. Percentages of reimbursement rates for kidney disease education (KDE) classes by year are shown by individual (G0420) and by group (G0421). Mean percentages of Medicare denials for all ICD-9 codes are shown as the right-most bars in each group by year.
individual and group classes, respectively. The American Medical Association reports that Medicare denials for 2011 were 3% of billings, which means that 4 times the number of KDE classes were denied as the average Medicare claim. In 2012, the KDE denial rate jumped to 23% for individual classes and 22% for group classes whereas the American Medical Association reported that Medicare denials increased to 4%. Thus, a KDE claim was more than 5 times as likely to be denied as a typical Medicare bill. To date, most denied claims come from the Palmetto Medicare Administrative Contractor serving South and North Carolina, West Virginia, and Virginia. The American Academy of Physician Assistants (AAPA) was notified by its members that denials were occurring when more than 1 class was taught on the same day. AAPA had previously received a written assurance from CMS that more than 1 class could be taught on the same day. AAPA was able to obtain a written assurance that 2 classes may be taught and paid for on the same day. However, without practices reporting denials, KDE classes may continue to decrease in volume and thus in importance to the nephrology community.25 To better assess the extent to which practices are using the MIPPA benefit and to determine who is being denied and why, another survey of practice patterns is planned.
Summary Research into kidney patient education is a relatively unexplored field. Looking to experience with patients with diabetes and heart disease, we can learn many lessons. The team approach has shown its value in those areas, and the lessons can also be applied to the kidney patient. Including patients in the team allows them to be partners and not passive recipients of care. The implementation of the KDE benefit for Medicare beneficiaries has not fulfilled its promise and needs to be pursued.
References 1. Koester L. Exploring the reasons for the tiny percentage of patients on home hemodialysis. Nephrol Nurs J. 2013;40(1):43-48. quiz 49. 2. Lewis AL, Stabler KA, Welch JL. Perceived information needs, problems, or concerns among patients with stage 4 chronic kidney disease. Nephrol Nurs J. 2010;37(2):143-148.
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3. Mendelssohn DC. Coping with the CKD epidemic: the promise of multidisciplinary team-based care. Nephrol Dial Transplant. 2005; 20(1):10-12. 4. Heatley SA. Optimal referral is early referral. Perit Dial Int. 2009;29(suppl 2):S128-S131. 5. Strand H, Parker D. Effects of multidisciplinary models of care for adult pre dialysis patients with chronic kidney disease: a systematic review. Int J Evid Based Healthc. 2012;10(1):53-59. 6. Hain DJ, Sandy D. Partners in care: patient empowerment through shared decision making. Nephrol Nurs J. 2013;40(2):153-157. 7. Sec Alt P, Schatell D. Teaching self-management: New Conditions emphasize patient participation in care. In: How to make the new Conditions for Coverage work in your dialysis clinic. Nephrology News & Issues. 2009;6:36-41. 8. King K, Witten B, Brown JM, Whitlock RW, Waterman AD. The Missouri Kidney Program's patient education program: a 12-year retrospective analysis. Nephrol News Issues. 2008;22(2):44-45. 48-52, 54. 9. Young HN, Chan MR, Yevzlin AS, Becker BN. The rationale, implementation, and effect of the Medicare CKD education benefit. Am J Kidney Dis. 2011;57(3):381-386. 10. National Kidney Foundation. Strategic Plan 2013-2018. Available at: http://www.kidney.org/about/strategic_plan/2013. Accessed May 23, 2014. 11. Coresh J, Byrd-Holt D, Astor BC, et al. Chronic kidney disease awareness, prevalence, and trends among U.S. adults, 1999-2000. J Am Soc Nephrol. 2005;16:180-188. 12. Fadem SZ, Walker DR, Abbott G, et al. Satisfaction with renal replacement therapy and education: the American Association of Kidney Patients Survey. Clin J Am Soc Nephrol. 2011;6(3):605-612. 13. Juergensen E, Wuerth D, Finkelstein SH, Juergensen PH, Bekui A, Finkelstein FO. Hemodialysis and peritoneal dialysis. Patient's assessment of their satisfaction with therapy and the impact of the therapy on their lives. Clin J Am Soc Nephrol. 2006;1(6): 1191-1196. 14. Hartzler A, Pratt W. Managing the personal side of health: how patient expertise differs from the expertise of clinicians. J Med Internet Res. 2011;13(3):e62. 15. Finkelstein FO, Yalamanchili HB, Kliger AS. Patient perceptions and experiences of ESRD care: quality and satisfaction. Am J Kidney Dis. 2013;61(3):366-367. 16. Harris LE, Luft FC, Rudy DW, Kesterson JG, Tierney WM. Effects of multidisciplinary case management in patients with chronic renal insufficiency. Am J Med. 1998;105(6):464-471. 17. Mason J, Khunti K, Stone M, Farooqi A, Carr S. Educational interventions in kidney disease care: a systematic review of randomized trials. Am J Kidney Dis. 2008;51(6):933-951. 18. Nunes JAW. Education of patients with chronic kidney disease at the interface of primary care providers and nephrologists. Adv Chronic Kidney Dis. 2013;20(4):370-378. 19. Becker BN. Focusing on health literacy might help us cross the quality chasm. Am J Kidney Dis. 2009;53(5):730-732. 20. Dageforde LA, Cavanaugh KL. Health literacy: emerging evidence and application in kidney disease care. Adv Chronic Kidney Dis. 2013;20(4):311-319. 21. Gordon EJ, Wolf MS. Health literacy skills of kidney transplant recipients. Prog Transplant. 2009;19(1):25-34. 22. Kutner NG, Johansen KL, Zhang R, Huang Y, Amaral S. Perspectives on the new kidney disease education benefit: early awareness, race and kidney transplant access in a USRDS study. Am J Transplant. 2012;12(4):1017-1023. 23. Fed Regist. 2009: 74(226): 2003. 24. Jacobs C. Costs and benefits of improving renal failure treatment— where do we go? Nephrol Dial Transplant. 2006;21(8):2049-2052. 25. Zuber K, Davis J, Rizk DV. Kidney disease education one year after the Medicare Improvement of Patients and Providers Ace: a survey of US nephrology practices. Am J Kidney Dis. 2012;59(6): 892-894.
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hen professionals gather, there is often the exchange of stories of times when patients' questions took us off guard. Often, we thought we had prepared our patients and their families by educating them on the disease process and their own progress. Then, a question comes out of the blue and makes us question what we have been missing. The following are just 3 of the many quotes that the authors have personally heard from patients. Each directed us to re-examine our approach. As we have shared them with others, we have found we were not unique: Other practitioners have had similar experiences and were likewise taken aback. “I know I have a touch of kidney disease.” This was spoken by a 68-year-old African-American female who smokes and is an overweight type II diabetic, is sedentary, and has an estimated glomerular filtration rate (eGFR) of 24 mL/minute/1.73 m2. “I want to donate my kidneys. Who do I call?” This question was asked to an advanced practitioner (AP) by a dialysis patient. “Oh, I have kidney disease?” This question was asked by a Stage 4 CKD 75-year-old patient who has been followed by nephrology for 11 years. These are real questions posed by real patients. Unfortunately, these are not isolated incidents.
The Scope of the Problem The nephrology community recognizes that CKD is approaching epidemic proportions. Data from 2010 show that 116,946 patients initiated renal replacement therapy (RRT) in the United States.1 Annual costs for hemodialysis (HD) and peritoneal dialysis (PD) in this country exceed From the Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL; and Metropolitan Nephrology, Alexandria, VA. Financial Disclosure: The authors declare that they have no relevant financial interests. Address correspondence to Jane S. Davis, DNP, Department of Nephrology, University of Alabama at Birmingham, 3605 Oakdale Road, Birmingham, AL 35223. E-mail: [email protected] Ó 2014 by the National Kidney Foundation, Inc. All rights reserved. 1548-5595/$36.00 http://dx.doi.org/10.1053/j.ackd.2014.03.013
338
$47.5 billion annually. In 2010, the National Kidney Foundation (NKF) estimated there were 26 million people with CKD and 8 million in Stage 3 or 4.2 The value of early referral to nephrology has long been known. Patients who are referred when their disease is well advanced reach end stage more rapidly, have increased incidence of associated conditions such as anemia and cardiovascular complications, are more prone to initiate dialysis with a catheter, have an increased hospitalization rate, and have poorer survival rates.3 The specter of an oncoming tide of kidney patients is not confined to the United States. The same prospects of an increasing number of patients with kidney disease are found in the United Kingdom.4 In Australia, between 7.5% and 11.4% of the population is estimated to have reduced kidney function.5 Awareness comes through education, and it takes a team to educate the patients and empower them to be active participants in their own care. The result can be a synergism of the parts. Patients who are informed and have the knowledge to participate are often are more likely to adhere to the care plan, have better outcomes, and are wiser users of healthcare resources.6 The composition of the health-care team (interdisciplinary team [IDT]) depends on the resources available. Ideally, it includes a nephrologist, AP, registered nurse (RN), renal dietitian (RD), social worker, pharmacist, and patient volunteers. Team members and their contributions to patient education vary widely based on resources and availability. The IDT is not a new concept. It has been promoted since the early 1990s. In fact, using the IDT for patient care is required in the Conditions of Coverage in the dialysis units.7 However, there have been few large-scale studies to support its use in the CKD clinic. One model kidney disease education (KDE) program, the Missouri Kidney Program initiated patient education in 1984. The 6 sessions were led by a renal social worker and the individual sessions were led by a social worker, RD, or RN. Topics included modality education, nutrition, and financial issues that patients face.8 Mendelssohn suggests 2 main reasons that the team is not more widely used.3 The first barrier he suggests is nephrologists' attitudes. The second is a lack of resources. Until IDTs can demonstrate a financial advantage in the clinical setting, their use will be limited. On the basis of
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limited evidence, Mendelssohn predicts that the team will choice and that dialysis has less of an effect on their lives prove its worth as a cost-effective measure by delaying than their HD counterparts.13 A 2003 study of ESRD patients' decision-making showed that although 41.5% of initiation of renal replacement therapy (RRT) and the patients wanted shared decision-making, 48.4% increasing the number of patients initiating RRT with a believed that decisions were being made for them without permanent access, choosing more home modalities and their input.6 requiring fewer hospitalizations. He contends that the Addressing these needs is a task for the entire team. The study of the economics of CKD is fairly new and it will roles of the nephrologist, AP, and RN are self-explanatory. take time and study to determine the dollar value of The other team members contribute by adding their experteam intervention.3 Education is the right thing to do for patients to protise to individualize care for the patients and their families. vide good care, and it has economic benefits. Patient edIn this case, the budget and resources are the limits, not the ucation has been associated with all of the benefits sky. suggested by Mendelsohn.3 The demographics speak Although the practitioner is the best resource for managfor themselves. Although the U.S. population with Stage ing and explaining the disease process, the RD can provide 4 CKD is less than 1%, the numbers have greatly 1-on-1 nutritional education and help the patient incorpoincreased over the last 20 years and the largest increase rate the dietary restrictions imposed by kidney disease into is in the patients over 65 years old.9 Education can often their lives. The social worker is invaluable for identifying delay the onset of dialysis, increase the use of home financial needs and accessing resources. If available, a therapies, and improve overall outcomes; however, papharmacist is valuable in educating patients regarding tients often report dissatisfaction with the information the multiple medications that most are prescribed. The they receive or a lack of knowledge of their disease pharmacist also serves as a staff resource regarding drug and options.9 Twenty-six million people in the United dosing, drug interactions, and new products. States have CKD, and nearly 1/3, or 8 million, are in The role of the patient volunteer is relatively unexplored. the late stages.10 It has been 1 of the author's What patients need to know experience that patients and what is important to often relate well to other paCLINICAL SUMMARY them varies with their stage. tients, and talking to someIn the early stages (1-3A), one who has “been there, Kidney disease is approaching epidemic proportions the focus needs to be on disdone that” is beneficial worldwide. ease management to prevent and reassuring. One finding Early referral to nephrology and education have or delay progression. In the showed that patients discuss demonstrated improved patient outcomes. later stages (3B-4), education more personal issues, The team approach to patient care is likely effective, but is more intense and should including how a condition aflarge scale studies are lacking. focus on medication, nutrifects one's daily life and tion, lifestyle, and financial coping strategies.14 MIPPA provides reimbursement for Medicare Stage 4 CKD The team approach is management as well as RRT patients, but is an under-utilized benefit. consistent with the emphasis modalities. It is in these on patient-centered care stages that involving all with the focus on shared available members of the decision-making and patient team is most beneficial. choice. The providers share with patients the information Patients rank knowledge of kidney disease, treatment for them to make their own decisions.15 This establishes a options, access care, and medication compliance as their partnership between the health-care providers and the pamost pressing issues. Maintaining social relationships tient as opposed to the former model in which the provider and activities is a prime concern for patients for when dictates the plan of care. The focus shifts from talking at the they initiate RRT. Kidney practitioners are well versed in patient to talking with the patient.1 symptom management. However, they may not always 2 recognize what the patient wants and needs to know. A Education report investigating the CKD awareness of U.S. adults In addition to a lack of familiarity with using the IDT showed that despite the increased numbers of patients with CKD, awareness remained low. The report also noted approach and the financial considerations, research in usthe same prevalence of CKD among Caucasians and Afriing teams for predialysis education is sorely lacking. The studies are often small, and practices vary in different can Americans, although there are 4 times as many African countries that have different medical models. Strand and Americans with ESRD. A 3rd finding was that the increased numbers of ESRD patients might be a result of Parker conducted an extensive literature review of studies comparing the IDT and the traditional model and the effect improved survival and earlier recognition of CKD.11 The American Association of Kidney Patients surveyed ESRD on patient outcomes. Initially, 927 articles published bepatients from their database and found that although tween 1990 and 2009 were considered; after evaluation, 4 nearly 70% reported receiving education about in-center met the criteria. Outcome measurements included laboraHD, only 58% reported being told of PD and 31% of tory values, blood pressure, time to dialysis, and quality of home HD.12 This is particularly concerning in that PD palife. Two of these were randomized control trials (RCTs) tients have reported increased satisfaction with modality and 2 were observational studies. Although the end points
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varied, 3 of the 4 showed positive outcomes with better blood pressure and diabetic control and 2 demonstrated delay to RRT initiation.5 One trial did not result in differences between the study and control group; instead, it showed the study population had an increased use of services.16 It should be noted that in this study the patients were seen in nephrology but were managed by their primary providers and the nephrology providers sent recommendations for their care. The authors concluded that although the IDT appears to have positive effects on patient outcomes, more well-designed RCTs are needed to support this indication.5 Another review that supported this indication studied RCTs that evaluated educational interventions with patients in early and late stages of CKD as well as dialysis patients. They found 22 reports that evaluated educational interventions, but most focused on diet and/or fluid compliance in dialysis patients. Only 1 was long term (20 years) on increased survival rates with a predialysis intervention. Overall, they found the studies to be of poor quality because of small sample sizes, inadequate reporting, and inconsistency in the interventions. Their review found positive outcomes from predialysis education despite the low numbers and quality of the study. The positive message is that the opportunity to make a meaningful intervention for patients exists.17 The future of CKD education is a mixture of good news and bad news. The good news is that the tools are available. There are multiple resources for patient and provider education. These are often provided at no cost or very low cost; they cover a wide range of topics; they come in languages other than English; and they include written, web-based, and video presentations. There are also provider resources with lesson plans, practice tool kits, and tracking programs.18 The bad news is that there are many tools available. The busy practitioner does not always have the time to sort through the many resources and evaluate the available information. Practitioners are not always well schooled in health literacy, and what makes perfect sense to a professional is often misunderstood by the patient. It is often difficult to find the resources that best apply to a particular patient population. The practitioner can begin with resources such as those available from the NKF Kidney Learning Systems and from the Medical Education Institute's Life Options. In addition, NKF and Life Options offer Power Point patient education programs.18 Recognition of health literacy is a relatively new issue. It is only in the last 20 years or so that it has been a topic of discussion. Populations with low health literacy have a higher number of morbidities and thus a higher use of health resources. Populations at risk include those who are older, have low education levels, and lower incomes. These are many of the same people at risk for CKD. Estimates are that 90 million people in the United States have basic or below-literacy skills and a greater number (110 million) lack basic mathematical skills. Health literacy is more than understanding a written statement; it is essential that the person be able to communicate with providers to make decisions.19 Complicating the issue is the lack of data. There have been studies in cardiology and endocrinology demonstrating the
value of improved patient conditions when health literacy issues were addressed. However, there are scant data on CKD patients' health literacy and very little on dialysis patients. Estimates are that up to 50% of patients on dialysis have limited health literacy, which is associated with poor blood pressure control, missed dialysis treatments, and increased emergency department use.20 Assessing a patient's health literacy is difficult. Although several tools exist, few are specific to the CKD population. Gordon and Wolf applied the Rapid Estimate of Adult Literacy in Medicine-Transplantation tool to 124 kidney transplant recipients. They found that although 91% of the kidney transplant recipients studied had adequate health literacy, many (81%) were unfamiliar with at least one term related to kidney transplant.21 Developing a practical health literacy tool is a challenge, but it must be pursued.
Patient Education As practitioners struggle with providing the right information to their patients and slowing disease progression, the patients struggle with understanding what is expected of them and incorporating changes into their lives. These changes often involve altering lifelong habits. Think of the Stage 4 CKD patient who has received extensive dietary instruction regarding salt, phosphorus, and potassium restriction. This patient attends an annual family reunion and is faced with a table groaning with fried chicken, macaroni and cheese, sausage biscuits, potato salad, watermelon, and homemade chocolate ice cream. Imagine the same patient's dilemma when friends at work plan a pizza party. In addition, the patient has been given a medication list that includes 1 tablet taken twice a day with food, 1 taken with every meal, 1 taken once a month, 1 taken at bedtime, and 1 taken in the morning and early afternoon. Is it any wonder there is confusion? The patient is confronted with a flood of information during a 15-minute clinic visit. Bicarbonate level, potassium, phosphorus, hemoglobin, iron, parathyroid level, and glomerular filtration rate—all of these are foreign to most patients, and after the visit, most would be hard pressed to explain what was important and why.
Medicare Improvements for Patients and Providers Act A major breakthrough occurred in April 2008, when the Medicare Improvements for Patients and Providers Act (MIPPA) authorized eligible providers (physicians, physician assistants, nurse practitioners, or clinical nurse specialists) to bill Medicare under their own National Provider Identifier number for KDE. Medicare beneficiaries with Stage 4 CKD are now eligible for 6 lifetime hours of KDE. In promoting this benefit, interested parties, including the Renal Physicians Association, the NKF, and the American Association of Kidney Patients, promoted early education to improve patient outcomes. These improvements were hoped to slow the patients' kidney function decline, to have modality education leading to initiation of RRT with a functional permanent access,10 and to increase kidney transplantation rates.21 Requirements for the classes are detailed in the Federal Register.22
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CKD Education
Table 1. Breakdown of Instructors and Sites by Year for Kidney Disease Education Classes by Group (G0421)
Class Site Office Nephrologists PA and NP General Medicine Hospital Medicine Total Office Outpatient Hospital Nephrologists PA and NP General Medicine Hospital Medicine Other (Lab, Dietitians) Total Outpatient Hospital Dialysis Unit Nephrologists PA and NP General Medicine Hospital Medicine Total Dialysis Unit Custodial Care Nephrologists PA and NP General Medicine Hospital Medicine Total Custodial Care Not Specified Nephrologists PA and NP General Medicine Hospital Medicine Total Not Specified Total Classes
2010
2010
2011
2011
2012
2012
Number of Classes
Percentage of Classes
Number of Classes
Percentage of Classes
Number of Classes
Percentage of Classes
407 938 25 0 1370
30 68 2 0
617 1343 30 0 1990
31 67 2 0
288 1124 46 0 1458
20 77 3 0
80 143 0 0 2 225
35 64 0 0 1
244 100 7 0 0 351
69 29 2 0 0
81 43 1 0 0 125
65 34 1 0 0
17 0 0 0 17
100 0 0 0
0 0 1 0 1
0 0 100 0
0 0 0 0 0
0 0 0 0
0 0 0 0 0
0 0 0 0
5 0 0 0 5
100 0 0 0
0 0 0 0 0
0 0 0 0
0 0 0 0 0 1612
0 0 0 0
35 4 4 0 43 2390
81 10 10 0
1 8 0 0 9 1592
11 89 0 0
Abbreviations: NP, nurse practitioner/clinical nurse specialist; PA, physician assistant. The total number of classes in 2010 ¼ 1612, in 2011 ¼ 2390, and in 2012 ¼ 1592.
The specifications set out in the Federal Register are at once specific and vague. A post-test is required, and the class content must be tailored to patients' individual needs. The test questions and methods of assessing those needs are left to the practitioner. Although MIPPA only authorizes reimbursement for providers with an National Provider Identifier, it does not exclude other members of the IDT from participating, nor does it state what percentage of each session must be led by the practitioner. This gives each practice leeway in offering the best education it can provide to its patients.23 KDE classes have been offered nationwide since 2010. Previous reports have found that most groups offer 2 classes/patient and are available to all CKD patients regardless of insurance.21 A review of the data from the KDE billing as released by the Centers for Medicare and Medicaid Services (CMS) showed trends that continue into 2012.22 Using the Public Use File that is released by CMS, all billed/paid KDE classes for 2010, 2011, and 2012 were reviewed. APs continue to dominate as the group class instructors in 2012 as they did in 2010 and 2011 (67%, 61%, and 74%, respectively) (Table 1). For individual clas-
ses, nephrologists are the dominant instructors for 2010, 2011, and 2012 (56%, 55%, and 47%, respectively). However, the percentage of individual classes taught by APs has grown from 2010 through 2012 (29%, 31%, and 34%, respectively) with classes taught in the home dominated by APs (Table 2). Although nephrologists have not participated in the teaching of home KDE classes, this site has increased by the largest percentage each year. There were 48 home classes in 2010, 283 in 2011, and 1336 in 2012 for a growth rate of 90% and 64%, respectively. Since the KDE class can be billed on the same day as an evaluation and management visit, the use of KDE for a longer counseling and education class for the CKD Stage 4 patient is an important armament for the home practitioner. Although the entire nephrology community fought for KDE classes, a worrisome trend is developing. KDE was authorized for billing in 2010, but because of a computer glitch, only 9 months of 2010 were billable.24 Thus, a large growth in billable classes from 2010 to 2011 was expected. This occurred in individual classes and group classes (16% and 33%, respectively). However, the growth in KDE classes is less evident from 2011 to 2012. Although there was
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Davis and Zuber
Table 2. Breakdown of Instructors and Sites by Year for Kidney Disease Education Classes by Individual (G0420)
Class Site Office Nephrologists PA and NP General Medicine Hospital Medicine Total Office Home Nephrologists PA and NP General Medicine Hospital Medicine Total Home Inpatient Hospital Nephrologists PA and NP General Medicine Hospital Medicine Total Inpatient Hospital Outpatient Hospital Nephrologists PA and NP General Medicine Hospital Medicine Total Outpatient Hospital Dialysis Unit Nephrologists PA and NP General Medicine Hospital Medicine Total Dialysis Unit Nursing Home Nephrologists PA and NP General Medicine Hospital Medicine Total Nursing Home Total Classes
2010
2010
2011
2011
2012
2012
Number of Classes
Percentage of Classes
Number of Classes
Percentage of Classes
Number of Classes
Percentage of Classes
2522 1286 566 4 4378
58 30 12 ,1
3131 1458 500 3 5092
61 29 10 ,1
2991 1454 524 3 4972
60 29 10 1
0 9 37 2 48
0 19 77 4
0 152 302 29 483
0 32 62 6
0 604 615 117 1336
0 45 46 9
10 5 7 0 22
45 23 32 0
0 1 0 0 1
0 100 0 0
1 0 0 0 1
100 0 0 0
5 117 0 0 122
4 96 0 0
10 140 18 0 168
6 83 11 0
32 113 0 0 145
22 78 0 0
9 0 1 0 10
90 0 10 0
3 0 0 0 3
100 0 0 0
17 2 9 0 28
61 7 32 0
0 0 0 0 0 4580
0 0 0 0
2 0 12 0 14 5761
14 0 86 0
0 0 0 0 0 6472
0 0 0 0
Abbreviations: NP, nurse practitioner/clinical nurse specialist; PA, physician assistant. The total number of classes in 2010 ¼ 4580, in 2011 ¼ 5761, and in 2012 ¼ 6472. General Medicine includes general practitioners, family practitioners, internists, neurologists, and gerontologists. Hospital medicine includes hospitalists, surgeons, physiatrists, emergency medicine, laboratory (2010 only), dietitians (2010 only), and obstetricians/gynecologists (2012 only).
an increase in the number of individual classes (5761 in 2011 to 6472 in 2012 for a growth rate of 16%), there was a loss of group classes (2390 in 2011 and 1592 in 2012 for a 50% loss) (Fig. 1). Adding all KDE classes together for 2010 to 2012, a disturbing trend is seen: although there was a 20% growth in KDE classes from 2010 to 2011 (6462 and 8151, respectively), there was actually a 1% loss in the number of classes from 2011 to 2012 (8151 and 8064, respectively). This decrease in KDE classes appears not to be because fewer classes were taught or billed but it is instead directly tied to an increase in the number of classes being denied by the CMS Medicare contractors (Fig. 2). In 2010, the denial rate for KDE classes was 1% for individual and group classes with denials for dietitian, labs and other nonauthorized KDE instructors. The 2011 denial rate was 14% and 17% for
Figure 1. Total numbers of kidney disease education (KDE) by year. KDE classes for years 2010, 2011, and 2012 by individual (G0420) and group (G0421) are shown.
CKD Education
Figure 2. AMA 2013 National Report Card Comparisons. Percentages of reimbursement rates for kidney disease education (KDE) classes by year are shown by individual (G0420) and by group (G0421). Mean percentages of Medicare denials for all ICD-9 codes are shown as the right-most bars in each group by year.
individual and group classes, respectively. The American Medical Association reports that Medicare denials for 2011 were 3% of billings, which means that 4 times the number of KDE classes were denied as the average Medicare claim. In 2012, the KDE denial rate jumped to 23% for individual classes and 22% for group classes whereas the American Medical Association reported that Medicare denials increased to 4%. Thus, a KDE claim was more than 5 times as likely to be denied as a typical Medicare bill. To date, most denied claims come from the Palmetto Medicare Administrative Contractor serving South and North Carolina, West Virginia, and Virginia. The American Academy of Physician Assistants (AAPA) was notified by its members that denials were occurring when more than 1 class was taught on the same day. AAPA had previously received a written assurance from CMS that more than 1 class could be taught on the same day. AAPA was able to obtain a written assurance that 2 classes may be taught and paid for on the same day. However, without practices reporting denials, KDE classes may continue to decrease in volume and thus in importance to the nephrology community.25 To better assess the extent to which practices are using the MIPPA benefit and to determine who is being denied and why, another survey of practice patterns is planned.
Summary Research into kidney patient education is a relatively unexplored field. Looking to experience with patients with diabetes and heart disease, we can learn many lessons. The team approach has shown its value in those areas, and the lessons can also be applied to the kidney patient. Including patients in the team allows them to be partners and not passive recipients of care. The implementation of the KDE benefit for Medicare beneficiaries has not fulfilled its promise and needs to be pursued.
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3. Mendelssohn DC. Coping with the CKD epidemic: the promise of multidisciplinary team-based care. Nephrol Dial Transplant. 2005; 20(1):10-12. 4. Heatley SA. Optimal referral is early referral. Perit Dial Int. 2009;29(suppl 2):S128-S131. 5. Strand H, Parker D. Effects of multidisciplinary models of care for adult pre dialysis patients with chronic kidney disease: a systematic review. Int J Evid Based Healthc. 2012;10(1):53-59. 6. Hain DJ, Sandy D. Partners in care: patient empowerment through shared decision making. Nephrol Nurs J. 2013;40(2):153-157. 7. Sec Alt P, Schatell D. Teaching self-management: New Conditions emphasize patient participation in care. In: How to make the new Conditions for Coverage work in your dialysis clinic. Nephrology News & Issues. 2009;6:36-41. 8. King K, Witten B, Brown JM, Whitlock RW, Waterman AD. The Missouri Kidney Program's patient education program: a 12-year retrospective analysis. Nephrol News Issues. 2008;22(2):44-45. 48-52, 54. 9. Young HN, Chan MR, Yevzlin AS, Becker BN. The rationale, implementation, and effect of the Medicare CKD education benefit. Am J Kidney Dis. 2011;57(3):381-386. 10. National Kidney Foundation. Strategic Plan 2013-2018. Available at: http://www.kidney.org/about/strategic_plan/2013. Accessed May 23, 2014. 11. Coresh J, Byrd-Holt D, Astor BC, et al. Chronic kidney disease awareness, prevalence, and trends among U.S. adults, 1999-2000. J Am Soc Nephrol. 2005;16:180-188. 12. Fadem SZ, Walker DR, Abbott G, et al. Satisfaction with renal replacement therapy and education: the American Association of Kidney Patients Survey. Clin J Am Soc Nephrol. 2011;6(3):605-612. 13. Juergensen E, Wuerth D, Finkelstein SH, Juergensen PH, Bekui A, Finkelstein FO. Hemodialysis and peritoneal dialysis. Patient's assessment of their satisfaction with therapy and the impact of the therapy on their lives. Clin J Am Soc Nephrol. 2006;1(6): 1191-1196. 14. Hartzler A, Pratt W. Managing the personal side of health: how patient expertise differs from the expertise of clinicians. J Med Internet Res. 2011;13(3):e62. 15. Finkelstein FO, Yalamanchili HB, Kliger AS. Patient perceptions and experiences of ESRD care: quality and satisfaction. Am J Kidney Dis. 2013;61(3):366-367. 16. Harris LE, Luft FC, Rudy DW, Kesterson JG, Tierney WM. Effects of multidisciplinary case management in patients with chronic renal insufficiency. Am J Med. 1998;105(6):464-471. 17. Mason J, Khunti K, Stone M, Farooqi A, Carr S. Educational interventions in kidney disease care: a systematic review of randomized trials. Am J Kidney Dis. 2008;51(6):933-951. 18. Nunes JAW. Education of patients with chronic kidney disease at the interface of primary care providers and nephrologists. Adv Chronic Kidney Dis. 2013;20(4):370-378. 19. Becker BN. Focusing on health literacy might help us cross the quality chasm. Am J Kidney Dis. 2009;53(5):730-732. 20. Dageforde LA, Cavanaugh KL. Health literacy: emerging evidence and application in kidney disease care. Adv Chronic Kidney Dis. 2013;20(4):311-319. 21. Gordon EJ, Wolf MS. Health literacy skills of kidney transplant recipients. Prog Transplant. 2009;19(1):25-34. 22. Kutner NG, Johansen KL, Zhang R, Huang Y, Amaral S. Perspectives on the new kidney disease education benefit: early awareness, race and kidney transplant access in a USRDS study. Am J Transplant. 2012;12(4):1017-1023. 23. Fed Regist. 2009: 74(226): 2003. 24. Jacobs C. Costs and benefits of improving renal failure treatment— where do we go? Nephrol Dial Transplant. 2006;21(8):2049-2052. 25. Zuber K, Davis J, Rizk DV. Kidney disease education one year after the Medicare Improvement of Patients and Providers Ace: a survey of US nephrology practices. Am J Kidney Dis. 2012;59(6): 892-894.
