Transcript When Kidneys Fail, They Stop…

Kidney Patient Job Retention:
The Next Rehab Frontier
Dori Schatell, MS
Medical Education Institute, Inc
Medical Education Institute
MEI Mission:
Help people with chronic disease learn to manage and
improve their health
MEI has worked on or developed:
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Original DOQI guidelines
Life Options™
Kidney School™
Core Curriculum for the Dialysis Technician
Fistula First
Medicare Dialysis Facility Compare website
Home Dialysis Central
Sen. Hartke Testimony: 1972
“60% of those on dialysis can return to
work but require retraining, and most of the
remaining 40% require no retraining
whatsoever. These are people who can be
active and productive,
but only if they have the
life-saving treatment
they need so badly.”
Life Options
Rehabilitation Program
Dedicated to helping
people live long and
live well with kidney
disease
Age of ESRD Patients
52% of incident ESRD patients are <65
0-19
2%
65+
48%
20-64
50%
N= 607,329
Data Source: USRDS 2003 ADR, Table C4, Incident ESRD Patients 1995-2002
Education of ESRD Patients
N = 1599
39.4%
700
600
500
20.5%
400
300
11%
9.8%
14.9%
200
3.8%
100
0
Š8th
10th
12th
Schatell D, Klicko K, Becker BN. Am J Kidney Dis. 48(2):285-91, 2006.
Degree
Job Loss is the Rule
Patients Age 18-55 at 90 Days Post Initiation, May 1995-June 2001
250,000
200,000
78,347
7,059
150,000
15,330
100,000
87,149
117,877
138,821
50,000
64%
60,713
37%
-22,457 jobs
-37%
38,256
23%
0
US Census
6 Mo. Prior
At Initiation
in thousands
Working
Not Working
Data Source: USRDS Special Data Request 2003
Missing Data
Job Loss/Disability Can
Impoverish ESRD Families
70,000
60,000
50,000
40,000
30,000
20,000
10,000
0
Mean
Family
Income
Private
Disability
(60%)
SSDI
(35%)
SSI
(Couple;
16%)
Effect of Job Loss on Patients
“Hi my name is X, i’ve been on dialysis for
3 years and im only 36 years old. i got it
from high blood pressure.
well now i have no friends and im
depressed and my life sucks. im a single
person with no job and no life. dialysis
sucks and i should just die.”
Actual quote from the dialysis_support
listserv, March, 2006
Effect of Job Loss on Patients
“I've been on hemo for 11 years now.
I lost my job at
Central Texas College because keeping up with dialysis
and my job was just too much. I lost my wife of 22
years and 3 children to another man because I began to
have sexual difficulties as a result of renal failure, which
by the way, Cialis, Viagra and Levitra just doesn't help.
I've developed carpal tunnel syndrome as a result of
calcium deposits in the wrists. And then try to live on an
SSI payment of $603.00 a month. It isn't easy let me tell
you. Since my divorce 7 years ago I have been bouncing
between friends. That's no life.”
Actual quote from the dialysis_support
listserv, August, 2006
Benefits of Work for Patients
 Self-esteem
 Higher income1
 Health insurance2
 Built-in social outlet
 Better physical functioning3
1Insurance
Information Institute, www.iii.org
2USRDS Special Data Request, May 20, 2003
3Blake et al. Physical function, employment, and quality of life in end-stage renal disease. J Nephrol
13(2):142-149, 2000
Functioning & Well-being:
PCS + MCS scores
Mental Component
Summary: MCS
Physical Component
Summary: PCS
Employment and FWB
 Employment predicted PCS and MCS in
African American CKD patients
Kusek et al. Cross-sectional study of health-related quality of life in African Americans with
chronic renal insufficiency: The African American Study of Kidney Disease and Hypertension
Trial. Am J Kidney Dis 39(3):513-524, 2002
FWB Scores Predict
Morbidity & Mortality
1 Point  in MCS
1 Point  in PCS
Mortality rate 0.46%
Hosp. rate 0.23%
Mortality rate 0.43%
Hosp. rate 0.43%
Lowrie EG et al. Medical Outcomes Study Short Form-36: A consistent and powerful predictor of morbidity
and mortality in dialysis patients. Am J Kidney Dis 41(6):1286-1292, 2003.
Benefits of Work for
Providers:
Two Dialysis
Revenue
Streams
Medicare
~ $130 per
treatment
+ meds
Renal Community
EGHPs
~ $350 per
treatment
+ 4x meds
Payer Mix & Dialysis
Revenues
Me dic are , e tc .
75%
EG HP
25%
Payer Mix: Community-wide
EGHP
Me di care, Etc.
Dialysis Revenue Sources
Clinic Revenue Per Patient/Year
Medicare-only vs. Employer Group Insurance
$60,000
$54,600
$50,000
$40,000
$30,000
$20,000
+$36,660
$17,940
$10,000
$0
80% Medicare @ $115/Rx
If EGHP @ $350/Rx
1-year Impact: Pt. Job Retention
vs. Composite Rate
 Increased revenue to the renal community of a 2.0%
composite rate increase for 377,313† patients:
$135 million
 First-year revenue to the renal community if previouslyworking patients kept working*:
$183 million
*6,922 patients in 2002 were working 6 months prior & not at initiation
†2005 projected population assuming 7% growth/year
Job Loss is the Rule
Patients Age 18-55 at 90 Days Post Initiation, May 1995-June 2001
250,000
200,000
78,347
7,059
150,000
15,330
100,000
87,149
117,877
138,821
50,000
64%
60,713
37%
-22,457 jobs
-37%
38,256
23%
0
US Census
6 Mo. Prior
At Initiation
in thousands
Working
Not Working
Data Source: USRDS Special Data Request 2003
Missing Data
How Do We Keep Patients
Working?
To Keep Patients Working…
 Reach patients early with information
 Treat predialysis anemia
 Offer work-friendly treatments
 Create an expectation that work is possible
Reach Patients Early with
Information
 % of patients who get predialysis
education?
How Can Networks Reach
Patients Early?
 Partner with:
• QIOs
• Industry
• Media
• Centers for Disease Control & Prevention
• Nephrologists
• Voluntary organizations
Treat Predialysis Anemia
“Not being able to get up in the
morning and be awake— it
almost feels like you need
another 2 or 3 hours of sleep.
And when you get home from
work or from a dialysis
treatment, you’re not just tired,
you’re utterly exhausted. So it’s
not like you come home and do
something else. You come
home and sleep.”
Treat Predialysis Anemia
“I finished my garage—I put up some pegboard and
some insulation. It took several weekends because
I couldn’t do it myself; I had a helper come over.
And at 40 [Hct], I could hammer nails. At 36, I
couldn’t. I’d take 2 or 3 swats at the nail and then
I’d be
winded. That’s kind
of incredible, isn’t it?”
Treat Predialysis Anemia
“I have pretty good
energy and I play 9
holes of golf, but when
it [Hct] gets below a
certain level, my energy
is shot. I’ll walk to the
mailbox, which is about
50 feet, and I’ll have to
stop and rest a while.”
Offer Work-Friendly Treatments
Patients Age 18-55 at 90 Days Post Initiation, May 1995-June 2001
50,000
44,012
40,000
30,000
26,157
34.5%
20,000
20.5%
10,910
7,879
10,000
49.2%
35.5%
0
4,301
61.1%
3,432
48.8%
Hemo
PD
Transplant
N=127,518
N=22,180
N=7,036
6 Mo Prior
Chi Square 247.711756752216, df = 2, p≤ 0.001
Data Source: USRDS Special Data Request 2003
At Initiation
Offer Work-Friendly Treatments
Dialysis “Choices” 2003
Center HD
92%
N = 324,826
Home
Hemo
0.3%
All PD
8%
Unknown
0%
USRDS 2005 Annual Data Report, Table D.1
Patients Not Told All Options:
1997
Before their first treatment
Patients told of in-center hemo: 89.7%
In-center patients told of HHD: 24.6%
In-center patients told of PD: 25.1%
USRDS 1997 Annual Data Report, USRDS Dialysis Morbidity and Mortality (Wave 2), p.
53.
Patients Not Told All Options:
2005
Among all incident patients in California:
Patients not aware of PD: 66%
Patients not aware of home hemo: 88%
Patients not aware of transplant: 74%
Mehrotra R et al, Kidney Int 2005 Jul;68(1)378-90.
What Makes a Treatment
Work-Friendly?
 Flexible or patient-centered schedule
 Fewer symptoms & hospitalizations
 Less restricted diet & fluids
Communicate the Relative
Burdens of Dialysis
In-Center
No schedule control
Strict diet/fluid limits
“Dialysis hangover”
Other patient deaths
Travel to/from clinic
Time off work/school
No choice of stick-er
Travel planning…
Home
Putting in needles
Dialysis emergencies
Order/store supplies
Space for equipment
Wiring/plumbing
Doing treatments
Alarms at night
Troubleshooting
Physiology of 3x/week
Hemodialysis
Weekly substance
concentrations in routine HD
Concentration
No normal range of ECV, K, Bicarb, P, Ca, pH
1
2
3
4
Time
5
6
7
Physiology
of
Daily
Dialysis
Weekly substance concentrations in daily HD
Concentration
Normal range of ECV, K, Bicarb, P, Ca, pH
1
2
3
4
Time
5
6
7
Work-friendly Treatments:
CAPD
Training takes 1 week
 Patient sets schedule
 Preserves residual renal
function longer
 Transplant is more likely
 1,549 US clinics
Work-Friendly Treatments:
CCPD
Abdominal catheter needed
Cycler does exchanges
 Possible manual exchange/day
Training: 1-2 weeks
1,524 US clinics
Baxter
HomeChoice
Fresenius Newton
Baxter
Fresenius
IQ Cycler
Freedom Cycler HomeChoice Pro
What Patients Say About PD
"PD and work go well together. I feel fine after
doing my exchange. PD is closer to what I
want out of life.”
“I thought about doing hemodialysis at the
dialysis center, but the people looked so wiped
out after their dialysis. Plus, I didn't have the
time to go in there 3 times a week. I've got work
to do!”
z
Connie
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see thi s pi cture.
Mary Ann
"I am so afraid of needles. I was only a little kid
when I had my first needles and problems with
my fistula. If you have to do dialysis, this is the
way to go!" Tish Sandoval
Work-Friendly Treatments:
Daily Home Hemo
2-2.5 hrs, 5-7 times/week
Training 2-8 weeks
Trained partner needed
132 US clinics
Aksys PHD
RenalSolutions
NxStage
System One Allient Sorbent
What Patients Say About
Daily Home Hemo
"I feel so much better. I dialyze seven
times a week."
Dadi Ding
“I feel great now! I have no up-anddown days and I feel very similar to
when I had no kidney failure.”
Jake Casey
"People shouldn't live to dialyze but to
have a life and do the things they were
meant to do."
Bill Peckham
Work-Friendly Treatments:
Nocturnal Home Hemo
Done 7-8 hours, 3-6 nights/week
Training takes 4-8 weeks
Trained partner is needed
127 US clinics
What Patients Say About
Nocturnal Home Hemo
"Now, I am able to work full time and fit my
treatments into my life!”
QuickT ime™ and a
T IFF (Uncompressed) decompressor
are needed to see thi s pi cture.
Melissa Bensouda
“On in-center dialysis, I felt like I was in
prison. I couldn't eat a tomato, eat cheese, or
drink milk. Now, you have control. You have
your life back.”
Sarah Taxman
“People who don't know that I'm on dialysis
can hardly even tell that I'm sick."
Wanda Wilson
How Can Networks Offer
Work-Friendly Treatments?
 Include information in patient &
professional newsletters & meetings
 Track & report availability by Network
 Gather thought leaders & practitioners
QuickTi me™ and a
T IFF (Uncompressed) decompressor
are needed to see thi s pi cture.
US: NHHD
QuickTi me™ and a
T IFF (Uncompressed) decompressor
are needed to see thi s pi cture.
US: DHHD
Create An Expectation That
Employment is Possible
 Share success stories in newsletters or
bulletin board displays
 Track & report employment data
 Include job retention as a topic in
meetings & QI initiatives
 Offer Life Options Patient Interest
Checklists (www.lifeoptions.org)
Conclusions
Job loss is the rule—but job retention
benefits patients, clinics, & the government
 Half of all ESRD patients are working-age
 ESRD Networks can help by:
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Reaching patients early with information
Encouraging treatment of predialysis anemia
Offering work-friendly treatments
Creating an expectation that work is possible