ESRD Care Research Articles

Functional representation of the network organisation of dialysis activities in France: A novel level for assessing quality of care.

To assess quality of care, groups of care units that cared for the same patients at various stages of end-stage renal disease, might be more appropriate than the centre level. These groups constitute "communities" that need to be delineated to evaluate their practices and outcomes. In this article, we describe the use of an agglomerative (Fast Greedy) and a divisive (Edge Betweenness) method to describe dialysis activities in France. The validation was based on the opinion of the field actors at the regional level of the REIN registry. At the end of 2018, ESRD care in France took place in 1,166 dialysis units. During 2016-2018, 32 965 transfers occurred between dialysis units. With the Edge Betweenness method, the 1,114 French dialysis units in metropolitan France were classified into 156 networks and with the Fast Greedy algorithm, 167 networks. Among the 32 965 transfers, 23 168 (70%) were defined in the same cluster by the Edge Betweenness algorithm and 26 016 (79%) in the same cluster by the Fast Greedy method. According to the Fast Greedy method, during the study period, 95% of patients received treatment in only one network. According to the opinion of the actors in the field, the Fast Greedy algorithm seemed to be the best method in the context of dialysis activity modelling. The Edge Betweenness classification was not retained because it seemed too sensitive to the volume of links between dialysis units.

Association of the Comprehensive ESRD Care Model with Treatment Adherence.

Poor adherence to scheduled dialysis treatments is common and can cause adverse clinical and economic outcomes. In 2015, the Centers for Medicare and Medicaid Innovation launched the Comprehensive ESRD Care (CEC) Model, a novel modification of the Accountable Care Organization framework. Many model participants reported efforts to increase dialysis adherence and promptly reschedule missed treatments. With Medicare databases covering 2014-2019, we used difference-in-differences models to compare treatment adherence among patients aligned to 1037 CEC facilities relative to those aligned to matched comparison facilities, while accounting for their differences at baseline. Using dates of service, we identified patients who typically received three weekly treatments and the days when treatments typically occurred. Skipped treatments were defined as days when the patient was not hospitalized but did not receive an expected treatment, and rescheduled treatments as days when a patient who had skipped their previous treatment received an additional treatment before their next expected treatment date. Patients in the CEC Model had higher odds of attending as-scheduled sessions relative to the comparison group, although the effect was only marginally significant (OR, 1.02; 95% CI, 1.00 to 1.04, P=0.08). Effects were stronger among females (OR, 1.03; 95% CI, 1.00 to 1.06, P=0.06) than males (OR, 1.01; 95% CI, 0.98 to 1.04, P=0.49), and among those aged <70 years (OR, 1.02; 95% CI, 1.00 to 1.05, P=0.04) than those aged ≥70 years (OR, 1.00; 95% CI, 0.96 to 1.04, P=0.96). The CEC was associated with higher odds of rescheduled sessions (OR, 1.09; 95% CI, 1.05 to 1.14, P<0.001). Effects were significant for both sexes, but were larger among males (OR, 1.11; 95% CI, 1.05 to 1.18, P<0.001) than females (OR, 1.07; 95% CI, 1.02 to 1.13, P=0.01), and effects were significant among those <70 years (OR, 1.12; 95% CI, 1.07 to 1.17, P<0.001), but not those ≥70 years (OR, 0.99; 95% CI, 0.92 to 1.07, P=0.80). The CEC Model is intended to incentivize strategies to prevent costly interventions. Because poor dialysis adherence may precipitate hospitalizations or other adverse events, many CEC Model participants encouraged adherence and promptly rescheduled missed treatments as strategic priorities. This study suggests these efforts were a success, although the absolute magnitudes of the effects were modest.

267 Characteristics of Nephrologists Participating in Medicare’s Comprehensive ESRD Care Initiative

267 Characteristics of Nephrologists Participating in Medicare’s Comprehensive ESRD Care Initiative

281 Impact of the Comprehensive ESRD Care Initiative on Nephrologists' Treatment of Patients With New-Onset Kidney Failure

281 Impact of the Comprehensive ESRD Care Initiative on Nephrologists' Treatment of Patients With New-Onset Kidney Failure

Accountable Care Organizations and Spending for Patients Undergoing Long-Term Dialysis.

Despite representing 1% of the population, beneficiaries on long-term dialysis account for over 7% of Medicare's fee-for-service spending. Because of their focus on care coordination, Accountable Care Organizations may be an effective model to reduce spending inefficiencies for this population. We analyzed Medicare data to examine time trends in long-term dialysis beneficiary alignment to Accountable Care Organizations and differences in spending for those who were Accountable Care Organization aligned versus nonaligned. In this retrospective cohort study, beneficiaries on long-term dialysis between 2009 and 2016 were identified using a 20% random sample of Medicare beneficiaries. Trends in alignment to an Accountable Care Organization were compared with alignment of the general Medicare population from 2012 to 2016. Using an interrupted time series approach, we examined the association between Accountable Care Organization alignment and the primary outcome of total spending for long-term dialysis beneficiaries from prior to Accountable Care Organization implementation (2009-2011) through implementation of the Comprehensive ESRD Care model in October 2015. We fit linear regression models with generalized estimating equations to adjust for patient characteristics. During the study period, 135,152 beneficiaries on long-term dialysis were identified. The percentage of long-term dialysis beneficiaries aligned to an Accountable Care Organization increased from 6% to 23% from 2012 to 2016. In the time series analysis, spending on Accountable Care Organization-aligned beneficiaries was $143 (95% confidence interval, $5 to $282) less per beneficiary-quarter than spending for nonaligned beneficiaries. In analyses stratified by whether beneficiaries received care from a primary care physician, savings by Accountable Care Organization-aligned beneficiaries were limited to those with care by a primary care physician ($235; 95% confidence interval, $73 to $397). There was a substantial increase in the percentage of long-term dialysis beneficiaries aligned to an Accountable Care Organization from 2012 to 2016. Moreover, in adjusted models, Accountable Care Organization alignment was associated with modest cost savings among long-term dialysis beneficiaries with care by a primary care physician.

The implication of American comprehensive ESRD care model in Taiwan health care policy

The implication of American comprehensive ESRD care model in Taiwan health care policy

Association between Freestanding Dialysis Facility Size and Medicare Quality Incentive Program Performance Scores

Background: Medicare uses a quality incentive program (QIP) criteria to evaluate care in dialysis facilities and apply monetary penalties on underperforming facilities. Smaller dialysis facilities are likely to be rural and operate on lower profit margin; therefore, such facilities are likely to underperform and face Medicare penalties. The variation in QIP scores by facility size is not yet known. We investigated the association between freestanding dialysis facility size and QIP scores. Methods: Our cross-sectional analysis compared QIP scores across levels of facility size for 5,193 freestanding dialysis facilities that received QIP scores in 2015. We used Medicare facility data including Dialysis Facility Compare, Performance Scores, Facility-Level Impact, and Area Health Resource and United States Renal Data System files for the payment year 2015. We measured the facility size using the number of dialysis stations per dialysis facility. QIP scores were used to determine the quality of care. A generalized linear model was estimated at an alpha level of 0.05. Results: Facilities operating more than 10 dialysis stations scored higher than those operating fewer. Further, facilities in the South and Northeast, not offering peritoneal dialysis, affiliated with chains (except chain 3) and spending more hours per dialysis achieved higher QIP scores. Facilities reporting a higher proportion of Hispanic patients and of patients with access to pre-end-stage renal disease (ESRD) nephrologist care achieved higher QIP scores. Conversely, facilities with a higher Black patient population and higher patient travel distances scored lower. Conclusions: The current study provides important finding about the performance of the dialysis facilities with ≤10 dialysis stations. Quality improvement strategies are needed, especially for the dialysis facilities with ≤10 stations, to prevent penalties and eventual closure of such facilities due to financial insolvency. Failure to address these issues will increase further disparities in ESRD care.

Pre-ESRD Care and Mortality in Incident ESRD Patients With Multiple Myeloma.

The relationship between mortality and pre-ESRD (end-stage renal disease) nephrology care in incident ESRD patients with multiple myeloma (MM) as the primary cause of renal failure has not been examined. Among 439,206 incident US hemodialysis patients with MM as the primary cause of ESRD (June 1, 2005 to May 31, 2009) identified using the US Renal Data System, adjusted odds ratios (OR) for reported pre-ESRD nephrology care for ESRD due to MM (n=4561) versus other causes (n=434,645) were calculated. The association of pre-ESRD nephrology care with subsequent mortality in MM-ESRD patients was examined. MM-ESRD patients were less likely to have any predialysis nephrology care in the year before initiation of dialysis (34.8% vs. 58.5%; OR=0.38; 95% confidence interval [CI], 0.34-0.43) compared with patients with ESRD due to other causes. MM-ESRD patients compared with others were more likely to have catheters on first dialysis (91.8% vs. 75.6%; OR=4.15; 95% CI, 3.54-4.86). Incident MM-ESRD patients receiving predialysis care for ≥6 months had significantly lower 1-year mortality (hazard ratio 0.89; 95% CI, 0.82-0.97 and 0.88; 95% CI, 0.80-0.96, respectively), relative to those without this care. A catheter for dialysis access was associated with a 1.6-fold increase in 1-year mortality in incident MM-ESRD (hazard ratio 1.55; 95% CI, 1.32-1.83). MM-ESRD patients were less likely to have predialysis nephrology care and more likely to use catheters on first dialysis. However, predialysis care is independently associated with lower mortality in MM-ESRD patients. Predialysis care should be prioritized in MM patients approaching ESRD.

Business of dialysis and the role of the medical director.

Since the inception of the Medicare End Stage Renal Disease Program in 1972, the medical director has been an important leader in the dialysis unit. The initial duties of the medical director were focused on quality and safety but were gradually expanded over the decades to include the development and oversight of protocols to manage metabolic bone disease and anemia. As the total cost of ESRD care has escalated, there have been progressive attempts to control costs through additional bundling and the creation of alternative payment schemes. While we await the financial and clinical outcomes of these initiatives, the medical director's role continues to expand in scope and now includes an enhanced role for not only clinical outcomes but financial outcomes as well.

The Journey to Full Health Care Responsibility for One ESCO Provider.

The Comprehensive ESRD Care (CEC) Model is designed to identify and evaluate new ways to improve care and reduce cost for Medicare beneficiaries with ESRD ([1][1]). With 24 Fresenius Medical Care North America (FMC) sites in the ESRD Seamless Care Organizations (ESCOs), we appreciate the opportunity

Integrating kidney transplantation into value-based care for people with renal failure.

Healthcare reimbursement is increasingly tied to value instead of volume, with special attention paid to resource-intensive populations such as patients with renal disease. To this end, Medicare has sponsored pilot projects to encourage providers to develop care coordination and population health management strategies to provide quality care while reducing resource utilization. In this Personal Viewpoint essay, we argue in favor of expanding one such pilot project-the Comprehensive ESRD Care (CEC) initiative-to include patients with advanced chronic kidney disease and kidney transplant recipients. The implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) offers a time-sensitive incentive for transplant centers in particular to align with extant CECs. An "expanded" CEC model proffers opportunity for robust cooperation between general nephrology practices, dialysis providers, and transplant centers to develop care coordination strategies for all patients with renal disease, realign incentives for all clinical stakeholders to increase kidney transplantation rates, and reduce total costs of care.

The Use of a Multidimensional Measure of Dialysis Adequacy-Moving beyond Small Solute Kinetics.

Urea removal has become a key measure of the intensity of dialysis treatment for kidney failure. Small solute removal, exemplified by Kt/Vurea, has been broadly applied as a means to quantify the dose of thrice weekly hemodialysis. Yet, the reliance on small solute clearances alone as a measure of dialysis adequacy fails fully to quantify the intended clinical effects of dialysis therapy. This review aims to (1) understand the strengths and limitations of small solute kinetics as a surrogate marker of dialysis dose, and (2) present the prospect of a more comprehensive construct for dialysis dose, one that considers more broadly the goals of ESRD care to maximize both quality of life and survival. On behalf of the American Society of Nephrology Dialysis Advisory Group, we propose the need to ascertain the validity and utility of a multidimensional measure that moves beyond small solute kinetics alone to quantify optimal dialysis derived from both patient-reported and comprehensive clinical and dialysis-related measures.

Continuous quality improvement in nephrology: a systematic review.

BackgroundContinuous quality improvement (CQI) has been successfully applied in business and engineering for over 60 years. While using CQI techniques within nephrology has received increased attention, little is known about where, and with what measure of success, CQI can be attributed to improving outcomes within nephrology care. This is particularly important as payors’ focus on value-based healthcare and reimbursement is tied to achieving quality improvement thresholds. We conducted a systematic review of CQI applications in nephrology.MethodsStudies were identified from PubMed, MEDLINE, Scopus, Web of Science, CINAHL, Google Scholar, ProQuest Dissertation s and sources of grey literature (i.e., available in print/electronic format but not controlled by commercial publishers) between January 1, 2004 and October 13, 2014. We developed a systematic evaluation protocol and pre-defined criteria for review. All citations were reviewed by two reviewers with disagreements resolved by consensus.ResultsWe initially identified 468 publications; 40 were excluded as duplicates or not available/not in English. An additional 352 did not meet criteria for full review due to: 1. Not meeting criteria for inclusion = 196 (e.g., reviews, news articles, editorials) 2. Not nephrology-specific = 153, 3. Only available as abstracts = 3. Of 76 publications meeting criteria for full review, the majority [45 (61%)] focused on ESRD care. 74% explicitly stated use of specific CQI tools in their methods. The highest number of publications in a given year occurred in 2011 with 12 (16%) articles. 89% of studies were found in biomedical and allied health journals and most studies were performed in North America (52%). Only one was randomized and controlled although not blinded.ConclusionsDespite calls for healthcare reform and funding to inspire innovative research, we found few high quality studies either rigorously evaluating the use of CQI in nephrology or reporting best practices. More rigorous research is needed to assess the mechanisms and attributes by which CQI impacts outcomes before there is further promotion of its use for improvement and reimbursement purposes.Electronic supplementary materialThe online version of this article (doi:10.1186/s12882-016-0389-1) contains supplementary material, which is available to authorized users.

Ready, Set, Go: Helping Physicians Move to Value as MACRA Begins

Passed with the broad bipartisan support of Congress in 2015, the Medicare Access and CHIP Reauthorization Act (MACRA) will bring about comprehensive changes to how Medicare pays for physician services. MACRA aims to accelerate the transformation from fee-for-service payment to alternative payment models that require physicians to assume risk for the cost and quality of care. Civen the nation's unsustainable healthcare costs, MACRA is expected to survive regardless of the outcome of the November presidential and congressional elections.MACRA is critically important legislation for all providers, not just physicians. This column addresses implications and challenges for hospitals and health systems and complements an earlier column by Bosko and Hawkins (2016) that examined implications for physicians and physician groups.A CATALYST FOR MOVING PHYSICIANS TO VALUEReplacing the long-contentious Sustainable Growth Rate formula, MACRA rewards physicians for providing value-based care through a two-track framework: The advanced alternative payment model (ARM) track incentivizes providers who are taking risk on the basis of the quality and cost of care for particular episodes or defined patient populations and requires use of certified electronic health record (EUR) technology. The Merit-Based Incentive Payment System (MIPS) track is based on the fee-for-service model but is directly and rigorously tied to performance in four areas: quality, resource use, advancing care information (use of EHRs), and clinical practice improvement.For most physicians participating in the Medicare program, inclusion in one of the two tracks is mandatory; those who do not select the advanced APMs track will be default participants in MIPS. Implications for both tracks begin imminently; performance reporting by physicians starts lanuary 1, 2017, for payment 2 years later, in 2019. Based on feedback received and to allow physicians time to obtain help and experience before the program affects them, the Centers for Medicare & Medicaid Services (CMS) may consider postponing implementation of portions of MACRA or shortening the reporting periods; but even with these possible changes, the time for physician and hospital and health system leadership teams to prepare is now.The MIPS track is revenue neutral, so there will be winners and losers. MIPS payment adjustment of up to 9%, plus or minus, is making small practices feel vulnerable, as indeed CMS projects to be the case: Buried in a table on page 215 of the 426-page proposed rule as published in the Federal Register (CMS, 2016), CMS's estimation is that 87% of eligible clinicians currently in solo practices and nearly 70% in practices with two to nine clinicians will experience a negative adjustment in payment beginning in 2019. In contrast, 81% of clinicians in practices with than 100 clinicians are expected to experience a positive adjustment in payment (Table 1 ).The stakes are high for those who participate in the APM track, which offers physicians and physician groups a 5% incentive payment through 2024. To qualify as an advanced APM, physicians and physician groups must meet financial standards for bearing risk for monetary losses, as well as eligibility thresholds based on Medicare volume or payment standards. The requirements as outlined by CMS are complex (CMS, n.d.), but the aim is clear: to ensure that qualifying APMs assume more than a nominal amount of risk-i.e., significant downside risk-for monetary losses under value-based payment contracts.CMS anticipates that these six models will qualify as advanced APMs in 2017 (Quality Payment Program, n.d.): Comprehensive ESRD Care (CEC)-two-sided risk; Comprehensive Primary Care Plus (CPC+); Next Generation ACO Model; Shared Savings Program-Track 2; Shared Savings Program-Track 3; and Oncology Care Model-two-sided risk. Additional models, such as a new voluntary bundled payment program, a new Medicare ACO+ track, and an amended Comprehensive Care for Joint Replacement (CJR) model, are being evaluated for possible inclusion in 2018 or later years. …

Conservative care for ESRD in the United Kingdom: a national survey.

Conservative kidney management (CKM) has been developed in the United Kingdom (UK) as an alternative to dialysis for older patients with stage 5 CKD (CKD5) and multiple comorbidities. This national survey sought to describe the current scale and pattern of delivery of conservative care in UK renal units and identify their priorities for its future development. A survey on practice patterns of CKM for patients age 75 and older with CKD5 was sent to clinical directors of all 71 adult renal units in the UK in March 2013. Sixty-seven units (94%) responded. All but one unit reported providing CKM for some patients. Terminology varied, although "conservative management" was the most frequently used term (46%). Lack of an agreed-upon definition of when a patient is receiving CKM made it difficult to obtain meaningful data on the numbers of such patients. Fifty-two percent provided the number of CKM patients age ≥ 75 years in 2012; the median was 45 per unit (interquartile range [IQR], 20-83). The median number of symptomatic CKM patients who would otherwise have started dialysis was eight (IQR, 4.5-22). CKM practice patterns varied: 35% had a written guideline, 23% had dedicated CKM clinics, 45% had dedicated staff, and 50% provided staff training on CKM. Most units (88%) provided primary care clinicians with information/advice regarding CKM. Eighty percent identified a need for better evidence comparing outcomes on CKM versus dialysis, and 65% considered it appropriate to enter patients into a randomized trial. CKM is provided in almost all UK renal units, but scale and organization vary widely. Lack of common terminology and definitions hinders the development and assessment of CKM. Many survey respondents expressed support for further research comparing outcomes with conservative care versus dialysis.

The medical director and quality requirements in the dialysis facility.

Four decades after the successful implementation of the ESRD program currently providing life-saving dialysis therapy to >430,000 patients, the definitions of and demands for a high-quality program have evolved and increased at the same time. Through substantial technological advances ESRD care improved, with a predominant focus on the technical aspects of care and the introduction of medications such as erythropoiesis-stimulating agents and active vitamin D for anemia and bone disease management. Despite many advances, the size of the program and the increasingly older and multimorbid patient population have contributed to continuing challenges for providing consistently high-quality care. Medicare's Final Rule of the Conditions for Coverage (April 2008) define the medical director of the dialysis center as the leader of the interdisciplinary team and the person ultimately accountable for quality, safety, and care provided in the center. Knowledge and active leadership with a hands-on approach in the quality assessment and performance improvement process (QAPI) is essential for the achievement of high-quality outcomes in dialysis centers. A collaborative approach between the dialysis provider and medical director is required to optimize outcomes and deliver evidence-based quality care. In 2011 the Centers for Medicare & Medicaid Services introduced a pay-for-performance program-the ESRD quality incentive program (QIP)- with yearly varying quality metrics that result in payment reductions in subsequent years when targets are not achieved during the performance period. Success with the QIP requires a clear understanding of the structure, metrics, and scoring methods. Information on achievement and nonachievement is publicly available, both in facilities (through the facility performance score card) and on public websites (including Medicare's Dialysis Facility Compare). By assuming the leadership role in the quality program of dialysis facilities, the medical director is given an important opportunity to improve patients' lives and effect true change in a patient population dealing with a very challenging chronic disease. This article in the series on the role of the medical director summarizes the medical director's specific role in the quality improvement process in the dialysis facility and the associated requirements and programs, including QAPI and QIP.

L’obésité est-elle un frein à la transplantation rénale ?

Kidney transplantation is the most suitable of ESRD care. The proportion of obese people is increasing in the general population and patients with kidney impairment. It is important to assess the impact of obesity on surgical complications of kidney transplantation. The aim of this retrospective study was to signify the correlation between obesity and the occurrence of postoperative urological complications during the first year. We conducted a retrospective study from March 1999 to December 2009. We conducted a chart review of patients undergoing kidney transplantation. The kidneys were taken from cadaveric donors. Data collected included age, weight, height, preoperative BMI; causal nephropathy, smoking, hypertension, diabetes, anticoagulation therapy. Intraoperative data included operative time (DO), cold ischemia. Urological complications were recorded during the first year after the kidney transplantation (vascular anastomotic strictures, ureterovesical stenosis, lymphorrheas, pyelonephritis, hematoma, wound infection). Statistical analysis consisted of a t-test for independent samples and univariate and multivariate logistic regression for the occurrence of complications. Four hundred and twenty-two patients were transplanted in total. We excluded 20patients. BMI and duration of surgery patients with complications were significantly different from those of patients with no complications (P=0.016 and P=0.039, respectively). Obese (n=48) had more diabetes (12.5% versus 3.7%, P=0.014), were more often smoking (35.4% versus 22%, P=0.012), had a longer DO (203.64minutes versus 182.46minutes, P=0.006), and complications (62.5% versus 50.28%, P=0.03) than patients with a BMI <30 (n=354). After adjusting for age, smoking, DO, diabetes and BMI showed that only BMI was an independent predictor of the occurrence of postoperative complications with P=0.048 and RR=1.058 [CI: 1 to 1.119]. However, there was no more transplantectomy obese (P=0.911). Our study showed that there is a significant risk of surgical complications after kidney transplantation in obese patients. But ultimately, this does not affect graft survival because there are no more transplantectomies or return to dialysis. 5.

A patient-centered vision of care for ESRD: dialysis as a bridging treatment or as a final destination?

The ESRD population is heterogeneous, including patients without severe comorbidity for whom dialysis is a bridge to transplantation or a long-term maintenance treatment, as well as patients with a limited life expectancy as a result of advanced age or severe comorbidity for whom dialysis will be the final treatment destination. The complex medical and social context of this latter group fits poorly in the homogeneous, disease-centered, and process-driven approach of many clinical practice guidelines for dialysis. In this commentary, we argue that the standards of treatment allocated to each individual patient should be defined not merely by his or her disease state, but also by his or her preferences and prognosis. In this more patient-centered approach, three attainable treatment goals with a corresponding therapeutic approach could be defined: (1) dialysis as bridging or long-term maintenance treatment, (2) dialysis as final treatment destination, and (3) active medical management without dialysis. For patients with a better overall prognosis, this approach will emphasize complication prevention and long-term survival. For patients with a limited overall prognosis, strictly disease-centered interventions often impose a treatment burden that does not translate into a proportional improvement in quantity or quality of life. For these patients, a patient-centered approach will place more emphasis on palliative management strategies that are less disease specific.

Does Hemodialyzer Reuse Have a Place in Current ESRD Care: “To Be or Not To Be?”

Seminars in DialysisVolume 27, Issue 3 p. 256-258 Dialysis Therapies and More: Things That You Should Know Does Hemodialyzer Reuse Have a Place in Current ESRD Care: “To Be or Not To Be?” Gerald B. Denny, Gerald B. Denny Department of Medicine, Vanderbilt University Medical Center, Nashville, TennesseeSearch for more papers by this authorThomas A. Golper, Corresponding Author Thomas A. Golper Department of Medicine, Vanderbilt University Medical Center, Nashville, TennesseeAddress correspondence to: Thomas A. Golper, MD, S-3303 Medical Center North, Vanderbilt University Medical Center, 21st Avenue South, Nashville, TN, 37232, Tel.: (615) 343 2220, Fax (615) 322 8653, or e-mail: [email protected].Search for more papers by this author Gerald B. Denny, Gerald B. Denny Department of Medicine, Vanderbilt University Medical Center, Nashville, TennesseeSearch for more papers by this authorThomas A. Golper, Corresponding Author Thomas A. Golper Department of Medicine, Vanderbilt University Medical Center, Nashville, TennesseeAddress correspondence to: Thomas A. Golper, MD, S-3303 Medical Center North, Vanderbilt University Medical Center, 21st Avenue South, Nashville, TN, 37232, Tel.: (615) 343 2220, Fax (615) 322 8653, or e-mail: [email protected].Search for more papers by this author First published: 21 March 2014 https://doi.org/10.1111/sdi.12232Citations: 3Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article.Citing Literature Volume27, Issue3May–June 2014Pages 256-258 RelatedInformation

Five policies to promote palliative care for patients with ESRD.

Patients with ESRD experience complex and costly care that does not always meet their needs. Palliative care, which focuses on improving quality of life and relieving suffering for patients with serious illnesses, could address a large unmet need among patients with ESRD. Strengthening palliative care is a top policy priority for health reform efforts based on strong evidence that palliative care improves value. This commentary outlines palliative care policies for patients with ESRD and is directed at policymakers, dialysis providers, nephrology professional societies, accreditation organizations, and funding agencies who play a key role in the delivery and determination of quality of ESRD care. Herein we suggest policies to promote palliative care for patients with ESRD by addressing key barriers, including the lack of access to palliative care, lack of capacity to deliver palliative care, and a limited evidence base. We also provide examples of how these policies could be implemented within the existing ESRD care infrastructure.