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Lowering costs for excellent kidney care

Nephrology practices that are proactive rather than reactive provide better care at a lower cost, Stanford researchers find.

The secret to spending less and improving care, at least for patients with kidney disease, seems almost too easy: Plan ahead.

"It requires that busy clinicians press the pause button on the day-to-day demands of patient care, step back and ask, 'How are we going to make this better?'" said Stanford nephrologist Brian Brady, MD.

Brady, along with researchers at the Clinical Excellence Research Center, took a close look at U.S. nephrology practices that deliver high quality care without excessive spending; they found several characteristics in common.

The overarching theme? "High-value practices are thinking much more proactively" when it comes to patient care, Brady said.

An article describing their work appears in the Journal of the American Society of Nephrology.

The researchers ranked hundreds of nephrology practices in terms of spending and quality. To determine spending per patient, they looked at health insurance claims. To determine quality, they evaluated how well the practices adhered to standards of care; for example, they looked at how frequently blood was drawn for lab analysis, whether patients were on the correct blood pressure medication for their condition, and if clinicians checked all the patients' medications to ensure they wouldn't interact with each other.

A researcher and a nephrologist then visited seven of the practices: three that ranked in the middle for both cost and quality and four that rated in the top 25%. The practices, scattered around the country, varied in size and patient population.

Unaware of the practices' ratings, the researchers spent a day at each one, interviewing clinicians and observing the routine. They found that the four high-value practices shared several features:

• They stave off health crises by monitoring the sickest patients closely, scheduling frequent office visits and laboratory checkups.

• They educate patients to stay on medications, recognize symptoms and pursue home dialysis.

• Medical assistants ensure that all relevant information -- such as discharge notes and laboratory results -- is completed before patients arrive for office visits.

• Nurse practitioners and physician assistants provide routine care, freeing up physicians to handle more complicated cases and diagnoses.

• Before patients require dialysis, physicians and nurses speak with them about undergoing a minor surgery to provide access for dialysis, thereby avoiding an emergency hospital admission.

While the research focused on nephrology practices, Brady noted that except for dialysis access surgery, the lessons apply to a variety of specialties, especially those that treat patients with chronic conditions such as heart failure, diabetes or chronic obstructive pulmonary disease.

"Keeping patients out of the hospital, promoting self-care, using clinicians at the top of their skill levels -- many of these apply to any practice," Brady said.

He added that adopting features of the high-value practices will take time and resources. But as Medicare reimbursements will soon reward practices for the value they offer, nephrologists are likely seeking ways to improve care quality while controlling costs.

"We hope this paper will help practicing nephrologists who are wondering where to start," he said.

Photo by TeroVasalainen

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