Tuesday, March 10, 2009

Should all Stage 3 CKD pts see a Nephrologist? What about "Stage 3b"?

That was essentially the question Dr. Nathan Hellman of the Renal Fellow Network asked when responding to the latest, 'it's-better-to-see-nephrologist-early-study'. More specifically he wondered whether the USA has enough nephrologists to handle the volume. This question has been raised previously. Our friends at DB's Medical Rants, suggest that there are currently approximately 7-8 million people with Stage 3 CKD and there are not enough nephrologists to care for each of them.

How many people have Stage 3 CKD? 7-8 Million I feel is a pretty rough estimate. There are different ways to determine and none are too precise. Are we using claims data? Then we are considering everyone who gets billed with an ICD-9 code of 585.3. Are we using the MDRD Eq? Do you believe everyone with acalculated estimated GFR of 55-59 ml/min truly has Stage 3 CKD? We know that the MDRD equation is not perfect and may underestimate the GFR. Now what about the sizable percentage of adults who do not seek medical attention? Do we extrapolate a number based upon a smaller sample? That said, the USRDS using the NHANES population gives us the most widely accepted data.

Do all Stage 3 CKD patients need to see a nephrologist? As a self-serving nephrologist within a young, hungry growing group of 5 nephrologists practicing in an area of high utilization and competition... my answer is not surprisingly, yes. I believe a PCP has a ton of issues to worry about in less and less time. We know that patients have better outcomes when they see a nephrologist early (for the latest study supporting this theory). Is it true that the problem is a shortage of nephrologist? I do not think the answer is as easy as # CKD stage 3 patients / # nephrologists. It is certainly not the case in the area of long island in which I practice. Although, I do believe there are wide regional differences throughout the country. Nevertheless, I concede it is probably impractical to see all CKD 3 patients in most areas... even with the recent growth in nephrology training programs.

Why aren't CKD Stage 3 patients seeing nephrologists? If we believe the data in regards to early nephrology referrals... is this being acted upon? Are all nephrologist's office busting at the seams from an overload of these CKD 3 pts? If not why? Are the PCPs concerned they will burden us? Are patients unaware or ill-informed about CKD? Are patients refusing to see 'another doctor'? Are nephrologists uninterested in treating CKD 3 pts? Perhaps there are other incentives such as the desire of the PCP to build their practice and avoid the potential of losing their patient?

Is there a conflict of incentives? There are now incentives in place to keep patients huddled close to their PCPs longer and longer. The use of specialists in general is frowned upon. Thus, there are growing pressures to minimize the utilization of all types of specialists across the board. These PCPs are the gatekeepers. They are supposed to ward off the evil subspecialists... and be the super-duper-do-it-all (and cost-containing) docs. All, of course within the confines of a 15 minute office visit. This trend clashes with the idea of the early nephrology referral.

What about the "Stage 3b's"? Maybe it is too much to ask.. and perhaps not appropriate for all CKD Stage 3 patients to be referred to a nephrologist. But I submit Stage 4 may be a bit late. Patients with CrCl <30>0.5-1 gram/d, suboptimal blood pressure control, or secondary hyperparathyroidism... I think this group of higher risk Stage 3 CKD patients would the most realistic group to target.

Anyway, I believe (and there is evidence to support) that there is value added in having a nephrologist as part of the TEAM in caring for a patient with CKD. Admittedly, there may in fact be a bit less value added in early stage 3 CKD (Stage 3a's). I think as a community later stage 3 or "CKD 3b" may be the best target.

What do you think?

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