Presentation on theme: "Using Physician Extenders to Create a CKD Clinic"— Presentation transcript:
1Using Physician Extenders to Create a CKD Clinic Theresa Becker, MSN, APNPMidwest Nephrology Assoc.Chronic Kidney Disease Clinic
2CKD Clinic The ideas of: Linking CKD Clinics & Anemia Management ProgramsUsing physician extenders in a multidisciplinary approachAre not new!
3CKD Clinic ADEPT Clinic Arizonia Disease Education Prevention & TreatmentStarted as an anemia management clinic but soon developed into a CKD ClinicPatients are referred to the Vascular Access Program when GFRs are mL/min.Curtis C, Yee B. The process of implementing a CKDClinic Nephrology News & Issues. 2005;19:53-54.
4CKD Clinic SHAPE UP Program Staging & Smoking Cessation Hypertension, Hyperglycemia, Hyperlipidemia, Hyperphosphatemia, Hyperparathyroidism, Hyperkalemia, & HypervolemiaAnemiaProteinuriaEvaluation for KRTUndo nephrotoxinsPreservation of veins & Patient educationGnanasekaran I, Kim S, Dimitrov V, Soni A. SHAPE UP-Amanagement program for chronic kidney disease Dialysis &Transplantation ;35:
5CKD Clinic One step further : A study by Curtis et al. suggested that even after appropriate & timely referral to a nephrologist, there is additional value of a multidisciplinary team approach in optimizing both short and long term patient outcomes.Curtis BM, Ravani P, Malberti F, et al. The short and long term impact of multi-disciplinary clinics in addition to standard nephrology care on patient outcomes.Nephrol Dial Transplant. 2005;20:
6Midwest Nephrology Associates CKD Clinic Model CKD Care PlanCKD StagingKDOQI Guideline Follow upCKDEducationPatientCommunityProfessionalVaccination ComponentFluPneumovaxHepatitis BAnemia Management ProgramAranespIron Therapy
7CKD Clinic Components of the CKD Care Plan GFR < 60 ml/min. HTN AnemiaNutritional Status/DMBone/Mineral MetabolismNeuropathyFunctioning & Well-beingDelaying Progression of CKD
8CKD Clinic Components of the CKD Care Plan GFR < 30 ml/min. Review Modality OptionsPreparation for chosen optionTransplant referralGFR < 15 ml/min.Tour ClinicMonitor for ESRD signs & symptoms
9CKD Clinic CKD Patient Education Topics CKD and consequences; anemia and bone diseaseCommon medications used in CKDAvoidance of nephrotoxic agentsKRT ModalitiesArm Preservation for HD access, Access placement & care of siteHealthy living
10CKD Clinic Access Teaching Pre AV access: Evaluation for appropriate arm such as vein mapping and instruction on saving that arm.Post AV access: Care of the site, exercising the access, and monitoring its development as well as instruction on its future use.
11CKD Clinic Documentation Medication List Clinical Action Plan Health MaintenanceClinic NoteSurgical Referral FormVascular Access RecordChart Label
12Surgical Referral Form CKD ClinicSurgical Referral FormDate: __________________Surgeon: __________________________ Phone: ______________ Fax: ________________Patient: _________________________________________________ DOB: _______________Nephrologist: ________________________ Phone: ______________ Fax: _______________PCP: ______________________________ Phone: _______________This patient is being referred to you for access placement. The desired access is an AV Fistula.In the event you are not planning to place an AV Fistula in this patient, please call the nephrologist prior to placing any other access.Patient’s non-dominant are is: Right LeftPatient has been saving the following arm: Right LeftComments (ie: arm injury/mastectomy/pacemaker/previous access):Vein Mapping done pre-referral: No Yes – Date/Location: ______________________Patient is currently on dialysis:Days: ____________________________________________________________________Location/Phone: ____________________________________________________________Patient is not on dialysis at this time:Anticipated hemodialysis start date: _______________________ monthsMost recent serum creatinine: ________ mg/dL & Creatinine Clearance/GFR: ________ ml/minPatient is on Anti-Coagulant Therapy: No Yes ___________________________________Allergies: NKDA Yes _______________________________________________________The following patient information is also enclosed: Face Sheet Vein Mapping Report H & P Recent Labwork Medication List
13Vascular Access Record CKD ClinicVascular Access RecordStage 4 (GFR < 30 ml/min): Surgical consult should be for ‘AVF Only’.Instruct Patient to Preserve Veins of Non-Dominant or Appropriate ArmObtain Vein MappingKDOQI Benchmark: AVF placement of > 65% for prevalent patients.
14CKD Clinic Surgeon ___________________ Date _______________ Right Arm _____Left Arm _____Direct AV Fistula:Transposition AV Fistula:PTFE Graft:Radial/Cephalic ____Radial/Basilic _____Straight _____Brachial/Cephalic ___Brachial/Basilic _____Loop _____Upper____Lower____
15Access Complication History CKD ClinicAccess Complication HistoryDateInterventionOutcome
16Save ____________________ Arm CKD ClinicChart LabelSave ____________________ ArmAccess Placed ___________________________________Flu Vaccine__________________________PneumovaxTetanusHepatitis B Vaccine#1 _______________________Recombivax-HB X 3#2 _______________________Engerix-B X 4#3 _______________________#4 _______________________Transplant Clinic _________________________________
21CKD Insurance Issues Office Visit Reimbursement Commercial Insurances reimburse NPs at 100% of MD chargesMedicare only reimburses NPs at 80% of MD chargesMedicare and a secondary insurance reimburses NPs at 100% of MD charges
22Anemia Management Program Erythropoietin Stimulating Agents (ESA)Available for Stage 1 – 5 CKD PatientsAgentSimilarity to EndogenousErythropoietinEstimatedT 1/2Initial DosingMaintenance DosingEpoetin alfa (Procrit)Ortho BiotechIdentical Immunologically~ 16 to 19 hoursunits/kg TIWTypical Dosing is u/kg weeklyGenerally weekly or QOW dosingDarbepoetin alfa(Aranesp)Amgen20% more carbohydrate content~ 33 to 48 hours0.45 mcg/kg/wkTypical Dosing is 0.9 mcg/kg QOWGenerally every 2 to 4 week dosingMcClellan, Schoolwerth A., Gehr, T. Clinical Management of Chronic Kidney Disease. Cadido, OK: Professional Communications, Inc.; 2006:
23ESA Agents Epoetin alfa Dose (Units/week) Darbepoetin alfa Dose (mcg/week)< 2,5006.252,500 to 4,99912.55,000 to 10,9992511,000 to 17,9994018,000 to 33,9996034,000 to 89,999100> 90,000200Aranesp Package Insert Amgen®
24ESA Agents Side Effect Profile HTN and Headaches Myalgias Diarrhea ContraindicationsUncontrolled HTNKnown hypersensitivity to the active substance or any of the excipients
25ESA Agents FDA Black Box Warning Issued 3/9/07 Use the lowest dose of ESA that will gradually increase the Hgb concentration to the lowest level sufficient to avoid the need for RBC transfusion.ESAs increase the risk for death and serious CV events when administered to target a Hgb > 12 gm/dL.
26Renal Physicians Association American Association of Kidney Patients ESA AgentsRPARenal Physicians AssociationRisks and benefits must be on individual patient basisEvidence based Hgb targets are helpful and should be reintroducedMay lead to unacceptably low Hgb levelsAAKPAmerican Association of Kidney PatientsWarning may be confusing to patients & providersSupports targeting Hgbs between 11 and 12Lower Hgb lead to concerns regarding QOL
30ESA Utilization Guidelines Hgb Level of < 11.0 gm/dL within 30 daysT. Sat. and/or Ferritin within 30 to 90 daysSerum creatinine within 30 daysPatient’s weight in kilogramsESA Dose per kilogramErythropoietin level is NOT recommended
31ESA Utilization Guidelines Target Hgb at or above 11.0 gm/dLCaution when intentionally maintaining Hgb > 13.0 gm/dLMonitor Hgb minimum of every 30 daysTarget Ferritin > 100 ng/mL and T. Saturation > 20%Monitor Iron Indices Quarterly
32ESA Utilization Guidelines Dose AdjustmentsIf Hgb increases by > 2 gm/dL per 4 weeks and/or Hgb level > 12 gm/dL, decrease dose by 20 to 25%If Hgb level is increasing < 1 gm/dL per 4 weeks, increase dose by 20 to 25%
33ESA Utilization Guidelines Dose Adjustments20 to 25% dose adjustments may be achieved by:Altering the ESA doseAltering the time interval between injections
34ESA Utilization Guidelines Dose AdjustmentsIncreases in dose should not be made more frequently than once a month.Avoid holding doses to avoid marked drop in ESA sensitive RBC precursors and the ‘seesaw’ effect of Hgb poor response pattern.
35ESA Utilization Guidelines Dose AdjustmentsMore frequent Hgb &/or iron indices monitoring may be necessary when:Recent bleeding or surgeryPost hospitalizationPost IV iron coursePeriods of ESA hypo-response
36ESA Utilization Guidelines ESA ResistanceInfection/InflammationBlood Loss, Guiac Positive StoolsHyperparathyroidismB12, Folate DeficienciesSickle cell, ThalacemiasMultiple Myeloma/MalignancyACE Inhibitor Use
37ESA Utilization Guidelines Dose AdjustmentsRecent data indicates Hgb levels can be maintained with every two week epoetin alfa dosing and monthly darbepoetin alfa dosing.Benefits include increased staff productivity and patient satisfaction/compliance.Moore T., Chookie S. Extended dosing od darbepoetin alfa in patients with chronic kidney disease not on dialysis: A review of recent data. Journal of ANNA 2005;32:
38ESA Utilization Guidelines Medicare considers doses exceeding 90,000 units per week for epoetin alfa or 200 mcg per week for darbepoetin alfa to be rarely reasonable and necessary. Medical justification for doses exceeding these amounts should be documented in the patient’s record.
40Hemoglobin Monitoring HemoCue vs. Lab DrawHemoCue Analyzer utilizes an optical measuring microcuvette. It provides nearly instantaneous Hgb results with very good accuracy.Traditional Lab Draw may be used. However, it will require another appointment or extended patient visit while awaiting lab results.
46ESA Insurance Issues Drug Assistance Drug company vouchers which generally allow one month supply of ESAESA samples may be available
47ESA Self Administration Initial TeachingESA script must include Anemia & CKD Stage ICD 9 codesInstruct patient on storage, handling, and observe administration of ESAOffice visit charge
48ESA Self Administration MonitoringMonthly HemoCue lab charge vs. traditional lab drawOffice visit charge
49New Agents Mircera Developed by Roche First and only Continuous Erythropoietin Receptor Activator (C.E.R.A.)Twice monthly dosing schedule, however generally will be able to administer monthly yet maintain stable Hgb levelsIV/SC administrationMay be used in CKD & dialysis patients
50IV Iron Iron Sucrose (Venofer) 100 mg/1 mL vial Administer 200 mg slow IV infusion over 2 to 5 minutes on 5 different occasions within a 14 day period. Typically dosed weekly for 5 weeks.Generally administered when Ferritin < 100 ng/mL and/or T. Saturation < 20%
51IV Iron Insurance Issues CPT Iron Billing CodeIron Sucrose – J1786 (Standard unit 1 mg)IV Infusion – 90765Office charge, high complexity visitICD 9 Iron Billing CodeIron Deficiency Anemia – 280.9