1. Improving Rural Access to Nephrology Care
Eric Wallace
Division of Nephrology

4. Only 3% of 4806 hospitals are
ranked in even 1 specialty.
• #46 in Nephrology
• #11 in Rheumatology
• #36 in Urology

5. Alabama Health Outcomes
•
•
•
•
#45 Overall Rank
#46 Diabetes Rank
#41 Smoking Rank
#47 Obesity Rank

6. How can you have one of the best hospitals in the
country and the worst outcomes in the same state?

7. Access to Care

8. Barriers to Access to Care
• Economic Barriers
• Insurance
• Co-pays
• Communication Barriers
• Language of Medicine
• Geographic Barriers
• Distance to drive to get to healthcare
• Lack of Adequate Transportation
• Money for Gas

9. Telemedicine's Potential in Nephrology
• Home Dialysis
• Delivery of Subsubspecialized Care
• Education

10. Home Dialysis

11. Renal Replacement Therapy
• In 2011, Medicare spent 34.3 Billion dollars on
the care of 507,000 dialysis patients
• Renal replacement therapy is needed when a
patient’s own kidney is unable to meet the
demands of the body.
• Currently there are 2 ways with which to replace
the function of the kidney
• Transplantation
• Dialysis

12. Types of Dialysis
• In Center Dialysis (90%)
• Go to a Center 3 times a week for 4 hours a treatment
• 1-2 hour recovery time
• Home Dialysis (10%)
• Home Hemodialysis (1%)
• Peritoneal Dialysis (9%)
• At home
• 7 day a week therapy but done while the patient sleeps

13. Standard Home Dialysis Delivery
• Patient undergoes training PD for 8 days and
HHD for 6 weeks.
• Begins to Dialyze at home
• Then the patient has a mandated monthly face to
face visit .

14. Equality, Autonomy, and Efficiency

15. Home Dialysis
Autonomy
• Self Care
• Improved Quality of Life
• Flexibility of the schedule not that of the Dialysis Unit

16. Efficiency
• Outcomes are equal
• $16,315 less expensive per year per patient than
hemodialysis
Lukowsky et al (2013)

17. Equality ???
Not for the Rural Population

18. Equality?

19. • Equality in Access to Care
Equality in Quality of Care
• of Care

20. Equality in Access to Care??
• Dialysis facilities in rural areas are less likely to
offer home dialysis than Urban Centers?
• Geographic barriers to home dialysis in that
peritoneal dialysis centers are located in urban
areas.

23. What does this mean for for the patient?
• Patients in rural areas don’t get put on home
therapies
• Patients on a home therapy in rural areas
sought out home therapies in urban areas
• Then once they are on the therapy they must
travel once monthly to a center
• Places an undue hardship on patients who
wish to care for themselves in their home to
do a home therapy

24. Equality in Quality of Care??
• Unfortunately training in Home Modalities in
Fellowship Programs has lagged behind that of InCenter Hemodialysis
• Since, only 9% of patient nationwide are on home
therapies experience remains low after training
This leads to poor outcomes in small
centers!

25. Higher Mortality and Rates of Transfer to
Hemodialysis

27. Summary
Autonomy- Home Dialysis increases patient autonomy
as it is self-care
Efficiency- Less Expensive Modality which delivers as
good of care with better patient satisfaction.
Equality- Home dialysis is not Equal in Quality or
Access to Care in Rural Alabama due to the distances
required for patient travel and lack of physician
expertise in these areas.

28. How Can We Change the Delivery of Care Paradigm
to Provide Equal Quality and Access to Care?

29. • Option 1: Build a lot of small home dialysis centers
in rural areas.
• Alabama- 23 more units
• Mississippi- 29 more units
• Tennessee- 16 more units
• Option 2: Eliminate the Monthly Face to Face visit.
• Option 3: Allow centers with expertise to reach out
to rural areas using telehealth, expanding access
to care.

30. Telehealth’s Potential for Home Dialysis
• Decrease Patient Travel Time
• Eliminate the Need for Small PD centers with
limited expertise in Home Dialysis
• Improve Access to Care
• Improve Patient Autonomy
• Improve Patient Choice of Physician
• Increase Efficiency
• If Alabama could increase from 10% to 20% PD. There
would be a savings of $12 Million per year.

31. Exporting Sub-Subspecialty Care
Fabry’s Disease

32. Fabry’s Disease
• Rare Genetic Disorder 1:40,000 patients
• Manifestations
• End Stage Renal Disease by the age of 40
• Congestive Heart Failure
• Stroke
• Neuropathy
• Requires sub subspecialized care by people who
understand this rare disease.

33. • UAB is a center of experience for this rare
disease and has one of the largest patient
populations in the country
• UAB’s Fabry’s clinic evaluates patients from
Georgia, Florida, Mississippi, and Kentucky
• Once a patient is identified, family screening is
necessary and those patients identified with the
mutation then need to be evaluated.

34. How Do We Improve Access to Care?

35. • Option 1: Care of the disease done by the
patient’s local geneticist, cardiologist, or
nephrologist
• The treatment of this disease costs $300,000 per
patient per year.
• Very difficult decision to decide who needs treatment
and more difficult now to decide who does not.
• Option 2: Telehealth visits in the evaluation and
follow up for these patients.

36. Why Aren’t We Doing This Already?

38. Regulations and Infrastructure
• Dialysis is very regulated and telehealth visits for
home dialysis are not currently covered by
medicare.
• Blue Cross/ Blue Shield Currently does not cover
any telehealth
• Fabry’s visits would be covered by existing
guidelines but there is currently limited telehealth
infrastructure in Alabama.
• This infrastructure could not be built based on the needs
of so few patients.

39. What is needed to proceed?

40. • Infrastructure
• Alabama Department of Public Health and the county health departments
• Alabama Partnership for Telehealth
• UAB satellite clinics
• Lists of Statewide health resources available
• Infusion Centers
• Outpatient Labs
• Radiology
• Regulatory
• Private payers such as Blue Cross/Blue Shield should reimburse these
visits.
• Designated rural areas should have the easiest access to telemedicine
• For sub sub specialized care such as Fabry's crossing of state lines needs
to be addressed with a National Medical License.

41. Conclusion
Technology is making our lives
easier.
Why shouldn't this translate into
easier access to care for our
patients?
Telemedicine holds the key to
transforming delivery of care, not
just in nephrology.

43. Questions?

44. Supporting Slides

45. Regulations
• Currently using telehealth for the monthly visit for
home dialysis is not permitted.
• Medicare ESRD telehealth coverage
90951,90952,90954,90955,90957,90958,90960,90961
• Not 90966- Home dialysis MCP

46. Regulatory Barriers
• Medicare
• This program could start today if there was a
Medicare exception for the Face to Face Visit
• Currently exceptions are granted on a case by case
basis
• And as such, protocolization of these visits in this
manner cannot currently be done
• Could be done as a clinical study and will need
minimal grant funding to start the program

47. Outcomes Based Clinical Trial
Clinical Measures Must be Equal to the patients
Being Treated In Center
• Hospitalizations
• Infection Rates
• Mortality
• Technique Survival
• Albumin
• Hemoglobins

48. Previous Experience?
• 1.6 million dollars in a Health Innovations Award
given to Susie Lew at Georgetown University.
Not to replace the Face to face visit (this is still
required) but to add more visits.

49. Ideas or Questions?

50. PERCENTAGE OF PREVALENT PATIENTS ON
PERITONEAL DIALYSIS BY COUNTRY
2000
2003
2006
2009
USRDS 2011 publication

51. Equality in Access to Care??
• In 1995 20% of patients in rural areas were on
peritoneal dialysis versus 10% on peritoneal
dialysis living in urban areas.
• Today in AL, MS, and TN the prevalent home
dialysis patient is equal whether you live in a rural
area or an urban area

52. PD and HD with AVF or Graft
HD with a CVC
Perl, J., Wald, R., McFarlane, P., Bargman, J. M., Vonesh, E., Na, Y., et al. (2011). Hemodialysis
Vascular Access Modifies the Association between Dialysis Modality and Survival.