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Moderation Versus Elimination for Kidney-Friendly Diets Dec 03, 2020

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Listen to this podcast, in which Sara Colman, RD, CDE, the manager of Kidney Care Nutrition for DaVita interviews Natalie Sexton, MS, RDN, CSR, LD, a dietitian for DaVita in Longview, Texas, on the importance of clinicians emphasizing moderation rather than elimination in a kidney-friendly diet. Natalie and Sara discuss the typical diets for end stage kidney disease patients on dialysis, including the different modalities of peritoneal dialysis, home hemodialysis and in-center dialysis. They examine how the kidney diet compares to some of the generally popular diets, what some of the biggest misconceptions are about kidney friendly diets, what some of the common barriers are that prevent diet adherence, how nutrition can affect quality of life, what overall goals dietitians have for their patients, how clinicians can advise patients to incorporate some of their favorite foods, even those that are not kidney friendly, in their diets and how to use the recipes on davita.com in meal planning and other nutrition resources available to patients and clinicians. Podcast Transcript: Sarah Colman, RD, CDE (00:43): Hello, and welcome to the DaVita Medical Insights Podcast. My name is Sarah Colman, RD, CDE and I'm the davita.com nutrition manager for DaVita kidney care. Over the past decade, we've seen a shift from a strict mineral based kidney diet to one that includes more healthy whole foods and even questioning the benefits of the old kidney diet. Today's can they diet continues to evolve with even more research. I'm excited to join on the phone today by Natalie Sexton, MS, RDN, CSR, LD, a dietician for DaVita in Longview, Texas, as we discuss the importance of clinicians emphasizing moderation rather than elimination and kidney friendly diet. Thank you for joining us, Natalie. Natalie Sexton, MS, RDN, CSR, LD (01:28): Hi, Sarah. Thank you for having me today. I'm very excited to be here and to be able to speak on such an important topic. Sarah Colman, RD, CDE (01:36): Great. Well, let's get started. Can you tell me about the typical diets for end-stage kidney disease patients on dialysis, including modalities such as peritoneal dialysis, home hemodialysis and in-center dialysis? Natalie Sexton, MS, RDN, CSR, LD (01:52): Yes, I do have a little disclaimer first. The diet guidelines that I'm talking about today are focused on patients who have what we call end-stage kidney disease. So they are on some form of dialysis. Nutrition recommendations are very different for people with chronic kidney disease, stage one through four or those trying to preserve remaining kidney function. So just to be clear, these diet guidelines we're going to talk about are focused on patients who are receiving dialysis treatment. So the most basic diet guidelines, once a patient's on a high protein diet, the dialysis treatment increases their calorie needs, their protein needs, so we do need them to increase their protein intake, which is something they may have not been used to if they had been following a low protein diet prior to dialysis. Natalie Sexton, MS, RDN, CSR, LD (02:55): We also want them to limit their potassium intake. So certain fruits and vegetables are going to be high in potassium. We would want them to try to limit those, cut back as much as possible. We also want them to watch their phosphorus intake. That's usually found in foods either naturally or sometimes your food companies add that as a preservative. So that's another thing that they have to watch out for. Low salt or low sodium is another one of the diet recommendations, and then low fluids. So sometimes patients on dialysis, you have to limit their fluid intake to avoid gaining too much fluid in their body. So that's pretty common for them to have to follow. Now, those are typically the recommendations for the in-center dialysis patients. Those are the patients that are coming usually three treatments a week. For the patients doing home dialysis, they may be doing shorter, more frequent dialysis treatments, so they may not have to be quite as strict with their diet. Natalie Sexton, MS, RDN, CSR, LD (04:14): Then they get a little more wiggle room since they are doing more frequent treatment. Then with PD, or peritoneal dialysis, the PD solution absolutely removes more potassium from the blood than just your standard hemodialysis. So those patients actually may have to follow a high potassium diet. They may be encouraged to eat certain foods that your in-center or your home dialysis patients are told to limit. Then also the PD solution is a kind of a sugar solution, so your body does absorb some of those calories. So this can cause problems with weight gain or blood sugar levels, so they may have to work with their dietician to try to modify their calorie or their carbohydrate intake. Sarah Colman, RD, CDE (05:12): Well, sounds like a lot to remember when it comes to kidney diets. Good thing we have the dieticians there to help work with patients and guide them in what they need for their individual needs. So we know that there's a lot of diets out there. It seems like every month or so we have a new popular fad diet. We have people who are eating keto or very low carb. We have other healthy type diets like Mediterranean Diet. So overall, how does the kidney diet compare to some of these popular diets or general healthy eating recommendations? Natalie Sexton, MS, RDN, CSR, LD (05:49): Yes, you're right. It seems like every month there's a news fad diet popping up. So usually when you hear the word diet, we think of cutting out certain foods or food groups or restricting yourself to a certain calorie amount until you reach a goal. So there's some sort of end goal in mind, like a certain dress size or a pants size or a number on the sale. There's some goal that the people following these diets are trying to reach. Natalie Sexton, MS, RDN, CSR, LD (06:28): So the difference between that and the kidney diet is the kidney diet is lifelong. Of course, we do have certain, I'll say, goals that we want you to achieve. We want certain blood levels to be within target ranges. We want you to meet what we call your target weight when you come in to your treatment. So we do have small goals, but as far as the true end goal, there really isn't one. This is a lifelong way of eating. So we really want to work with our patients and help them create actions that they can implement forever. Sarah Colman, RD, CDE (07:16): Natalie, I find that there are a lot of patients who come to dialysis with so much confusion, and I think part of that is because in earlier stages of kidney disease, they may or may not need a low potassium diet. They may be restricting protein to help decrease waste buildup in their blood. Then a person comes to dialysis, all of a sudden they may not be eliminating enough fluid, the kidneys are starting to shut down more and more. So I think this causes a lot of confusion when a person comes to the dialysis center and starts dialyzing, and they're unsure. They have mixed messages about what to eat, what not to eat, what their allowances are. So in your eyes, what are some of the biggest misconceptions that you hear about kidney friendly diets? Natalie Sexton, MS, RDN, CSR, LD (08:08): Some of the biggest things that I hear that are definitely not true is that you can never eat a high potassium fruit or vegetable ever again. Probably the most common high potassium fruits or vegetables are bananas, tomatoes, avocados. So it's definitely a myth that you can never, ever have a single bite of those foods ever again if you're on dialysis. If anyone has ever looked at the DaVita website with our recipe book or cookbook, we have recipes that have avocados, tomatoes, bananas, potatoes, but they're all in moderation or smaller portions. So we still do want to work these foods into our diet. They can provide a lot of flavor, a lot of color to our meals, but we just have to watch how much we eat at one time. Natalie Sexton, MS, RDN, CSR, LD (09:16): Another myth is that the diet is just simply too hard to follow, and yes, it is very complex, but it's not impossible. We're not asking our patients to track their potassium intake down to the very last milligram. I don't ask mine to even really track their grams of protein. We simplify it as much as we can and try to make it very doable. So I encouraged them to do more of just asking themselves, "Does this meal include any high protein food?" So rather than count grams of protein, I just want them to say if a high protein food is included in the meal. So for example, a patient told me yesterday that their breakfast was usually a couple pieces of toast and some black coffee. So we talked about how that didn't have a lot of protein in it. So we talked about adding an egg or two to try to get their protein intake up. Natalie Sexton, MS, RDN, CSR, LD (10:31): So once you're sure you've got some good protein with that meal, I encourage them to ask themselves, "Are there any high potassium foods that I need to watch out for?" So if they are out at a restaurant, if the side for their meal was going to be potatoes, which we know have a lot of potassium in them, if that's something they're trying to cut back on, then we can see if we can swap that out for a lower potassium vegetable. Then third question is, "Are there any high phosphorus foods I should be careful of?" So I teach my patients to be able to identify some typical hight phosphorus foods, which ones to try to avoid as much as possible and which ones to cut back on. So for example, cheese is one of the more common high phosphorus foods. So I encourage them to either use a smaller portion or ask for the tea to be put on the side of the plate so that they can control the amount on there. Natalie Sexton, MS, RDN, CSR, LD (11:41): So I would say compared to calorie counting and macro counting and the true keto diet where you're watching every last gram of carb that you serve yourself, honestly, the kidney diet seems a lot easier than that. Sarah Colman, RD, CDE (12:04): But that really makes a difference. I know as soon as you tell me not to eat something, especially if it's something like chocolate that I really love, I'm going to start craving it. So I'm sure for dialysis patients, just knowing that if there's something you truly want to eat, there is a way to work it into your diet. It's working with your dietician and finding out what's the results after you've added that item. I think as clinicians that's one thing that we can do, is just really give that flexibility but also monitoring the effects of making changes in a person's usual renal diet. So Natalie, as a dietician, what are some of the common barriers that you see that prevent diet adherence? Natalie Sexton, MS, RDN, CSR, LD (12:54): Definitely I would say with a patient who's new to dialysis, a lot of times they're just very overwhelmed. Their whole life has suddenly changed. Depending on what type of dialysis they're doing, let's just say they're doing in-center dialysis, so that means all of a sudden for three or four hours at a time, three or four times a week, depending on their dialysis constrictions, suddenly they have to be in this dialysis center, hooked up to a machine, there's monitors everywhere, there's beeping, there's blood, there's needles. It's actually kind of scary when you think about it. As comforting as the teammates try to be with all the patients, it is a very overwhelming life altering thing to start dialysis. Natalie Sexton, MS, RDN, CSR, LD (13:56): So in addition to dealing with all that, now we want you to remember all these different food rules and only eat these few foods and don't eat anything that you enjoy eating, it's a little unrealistic for us to expect that from our patients. So that's probably the first barrier that I see, is they're just not ready to take in the education fully just yet, or they're just overwhelmed with everything and they can't quite focus on that. So just working with them, small changes that they can make over gradual amount of time helps. Like you said, there's certain foods that you may find comfort in like chocolate or ice cream. Where if I go tell you, "Okay, no more chocolate, no more ice cream, no more this, no more that," that suddenly is just consuming your mind. That's all you think about. That's all you crave. So for someone to kind of take away that last little bit of comfort is very frustrating, very overwhelming. Natalie Sexton, MS, RDN, CSR, LD (15:11): Another barrier would be just the lack of understanding. Our patients are just like anyone else. They're flooded with the messages from the TV commercials and the late night infomercials and the magazines about the latest fad diets. So sometimes it's just kind of a disconnect between what the media tells us, what our friends following the latest fad diet or selling a weight loss supplement is telling us, and then what our dialysis dietician is telling us. So it can all be very confusing and kind of mixed messages there. A lot of the patients haven't had true diet education before. So this may be their first experience ever being told to watch what they eat and things like that. So definitely just lack of understanding is another barrier. Sarah Colman, RD, CDE (16:20): I think that with that, often patients are given food lists and the list may say foods you can eat. Foods to avoid or limit. That focus is so much on the word avoid, but you have to remind patients that it says, "Or limit." So there may be some foods on that list that, yes, you do need to avoid altogether, but often there's many foods on that list that that can be included. It's just limiting the amount and the frequency. I think that's one thing that we can do as clinicians, is help patients to understand that that's their focus, that it's not as strict or as awful or as bad as they initially might think that changing their diet can be. Sarah Colman, RD, CDE (17:10): So we think a lot about quality of life with our patients and we know that when a person is not getting the right nutrient balance, if they're malnourished, if they're having appetite problems or maybe they just have that fear of eating, that can all affect a person's quality of life. So in your eyes, Natalie, how can nutrition affect quality of life and what can we do to improve it through better nutrition? Natalie Sexton, MS, RDN, CSR, LD (17:45): Nutrition does play a big role in quality of life. So although following the kidney diet won't reverse the need for dialysis, it can help them manage some of the symptoms that they may be dealing with. So watching their salt intake, it's more than just we don't want you to eat all the salt. Watching their salt intake will help decrease their blood pressure, which can help them avoid a stroke or a heart attack. Watching their fluid intake helps them breathe easier, and it keeps their heart from having to work harder from carrying all this extra fluid weight around. Limiting their calcium and their phosphorous intake helps them improve or preserve their bone health, so it keeps their bones strong and healthy. Limiting their potassium intake can help avoid issues with heart rhythms, eating a high protein diet will help keep their albumin level up which helps keep their bodies healthy and they feel well, they have more energy. Natalie Sexton, MS, RDN, CSR, LD (19:09): Then we can also work with our patients on if they have diabetes and they want to help manage their blood sugar levels, or they wa…

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The Importance of Influenza Vaccination during the COVID-19 Pandemic Nov 12, 2020

Show notes

Receiving the influenza vaccine has always been important for patients with kidney disease, but the COVID-19 pandemic makes influenza vaccinations even more crucial now. Listen to this podcast, in which Mandy Tilton, DNP, MSN, MBA, RN, CNN, chief nursing officer for DaVita Kidney Care interviews Jeffrey Giullian, MD MBA, FASN, chief medical officer for DaVita on why influenza vaccination is so crucial and whom he recommends be vaccinated during the pandemic. Dr. Giullian and Mandy also dispel some myths about the flu vaccine, state which form of the vaccine is most effective, discuss the benefits and safety concerns of getting vaccinated during spikes of COVID-19 prevalence in patients’ communities and provide guidance for clinicians in speaking with patients about influenza vaccination.

Podcast Transcript:

Mandy Tilton, DNP, MSN, RN (00:44): Hello and welcome to the DaVita Medical Insight Podcast. My name is Mandy Tilton and I have the honor of being the chief nursing officer for DaVita Kidney Care. I'm excited today to be joined on the phone with Dr. Jeffrey Guillian, who is our chief medical officer for DaVita, and today we will discuss the importance of influenza vaccination during the COVID-19 pandemic. Thank you for joining us, Dr. G.

Dr. Jeffrey Guillian (01:12): Hey Mandy, I'm glad to be able to speak with you on such an important and timely topic.

Mandy Tilton, DNP, MSN, RN (01:18): Timely it is. Receiving the influenza vaccine has always been important, but why does the COVID-19 pandemic make it even more crucial now?

Dr. Jeffrey Guillian (01:29): Well, Mandy, as I'm sure you can imagine, the flu season is going to be particularly complicated this year given the similarities in symptoms between influenza virus and COVID. And more than any other year, it's really important that all patients and teammates get vaccinated for the flu. Last season, unfortunately, less than half of all Americans got a flu vaccine and at least 410,000 people were hospitalized.

Dr. Jeffrey Guillian (01:54): And remember, that although we don't yet have a vaccine for COVID, we do have a vaccine for the flu. And by getting the flu vaccine, you are also helping to protect the people around you. And this is something known as herd immunity. If the majority of the population is vaccinated against the flu, it then reduces the entire community's risk, particularly for vulnerable patients. And preventing the flu supports good stewardship of resources. Even if your illness doesn't require a hospitalization, it helps avoid visits to the doctor, where you might go if you want to confirm that you actually do have the flu.

Mandy Tilton, DNP, MSN, RN (02:31): And knowing all of this, who do you think should be recommended to obtain influenza vaccination during the COVID-19 pandemic?

Dr. Jeffrey Guillian (02:41): Well, annual flu vaccine is recommended for everyone six months of age or older, so that's certainly all of us listening, except for rare exception, because it is an effective way to decrease the flu illness, decrease hospitalizations, and certainly to decrease deaths. During the COVID-19 pandemic, reducing the overall burden of respiratory illness is an important way to protect vulnerable populations at risk for severe illnesses, and it protects the health care system, and it protects critical infrastructure.

Dr. Jeffrey Guillian (03:12): And I want to highlight one vulnerable population, and that's obviously our patients, those with kidney disease. This group of individuals is at high risk for both severe COVID and severe flu. Clinicians should use every opportunity during the influenza vaccination season to administer influenza vaccines to every eligible person. And time is of the essence. It takes around two weeks after the vaccination to achieve immunity, so don't wait until your friend or your neighbor tells you that they've got the flu. Get vaccinated now.

Dr. Jeffrey Guillian (03:45): And that brings up an important point. I have certainly heard some people say they are planning on getting the flu vaccine this year because they're already wearing a mask. Now, Mandy, what is your suggested guidance for clinicians who are approached with this thought, by either their patients or their colleagues?

Mandy Tilton, DNP, MSN, RN (04:01): Well, that is an important thing to cover. A mask is great and it is a really important barrier for infections, but it's certainly not perfect for stopping the spread of flu. I would encourage us to think about it this way. When we get into cars, we put on seatbelt. I'm guessing most of us all do that even though our car may have safety features like airbags, but we want to keep ourselves as safe as possible. And while the airbags are great and helpful, combined with the seatbelt, they're even better. The same is really true when we think about fighting the flu. Masks are great. In this case, they're your airbags. The vaccine, however, is your seatbelt.

Mandy Tilton, DNP, MSN, RN (04:47): And while we're on the subject of dispelling this, can you help us answer a question that many of us are hearing from patients and others? And that question is, can I get the flu from the flu shot?

Dr. Jeffrey Guillian (05:02): No, you cannot. You absolutely cannot get influenza from the flu shot. You can get a sore arm, and trust me, I just got my flu shot and my arm was sore. And you can get some achiness, which is proof that your immune system is waking up and becoming activated, but you cannot get the influenza virus itself. Real influenza is a life-threatening viral infection.

Dr. Jeffrey Guillian (05:25): Help me, Mandy, if individuals do want to get the flu vaccine, what is your suggested guidance on receiving the nasal flu preparation in its place?

Mandy Tilton, DNP, MSN, RN (05:36): The injectable form of the vaccine has proven to be more effective, but even the nasal option is more effective against influenza than receiving no vaccine at all. It's important to remember though, that the nasal spray is not for everyone, particularly those with a compromised immune system. If you or a patient are interested in the nasal spray vaccine, please do first discuss this with your physician.

Mandy Tilton, DNP, MSN, RN (06:06): Dr. G, can you help provide some insight on whether the influenza vaccine will protect individuals against COVID-19?

Dr. Jeffrey Guillian (06:16): Well, sure, Mandy. I think it's important to remember that getting an influenza vaccine will not protect against COVID-19 directly; however, influenza vaccination has many other important benefits. Influenza vaccines have been shown to reduce the risk of getting the influenza virus and the illness, and hence hospitalizations and deaths. And getting an influenza vaccine this fall will be more important than ever, not only to reduce your risk from the flu, but also to help conserve potentially scarce healthcare resources as we discussed earlier. Many intensive care units are already full with people with COVID.

Dr. Jeffrey Guillian (06:52): Now, Mandy, how would you suggest clinicians respond to patients who wonder if it's safe to get an influenza vaccine if COVID-19 is spreading in their community?

Mandy Tilton, DNP, MSN, RN (07:01): Well, as clinicians, we can remind patients to practice everyday preventative actions and follow CDC recommendations for things like running essential errands. We can tell patients to ask their doctors, pharmacists, or health departments whether they are following the CDC's vaccination pandemic guidance. And any vaccination location following CDC's guidance should be a safe place for them to obtain their influenza vaccination.

Mandy Tilton, DNP, MSN, RN (07:36): I think we've covered a lot, but do you have any additional guidance for clinicians as they speak with patients about the influenza vaccine?

Dr. Jeffrey Guillian (07:45): Absolutely. Please remember, people call lots of bad colds the flu, and this is unfortunate and it's not accurate. The real influenza A and B viruses can be life-threatening and make you feel much, much worse than a bad cold. The flu vaccine doesn't stop you from getting a cold, even a bad one, it does, however significantly reduce the risk that you or your patients or your loved ones will get the actual flu, and that, that might just save a life.

Mandy Tilton, DNP, MSN, RN (08:18): Well, Dr. G, thank you for joining me and discussing the importance of influenza vaccination during this ongoing COVID-19 pandemic.

Dr. Jeffrey Guillian (08:28): Well, thanks for having me, Mandy. I appreciate you having this opportunity.

Mandy Tilton, DNP, MSN, RN (08:32): And listeners, thank you all for tuning in and be sure to check out other DaVita Medical Insights episodes for more kidney care educational podcasts. You can also find additional kidney care thoughts, leadership and industry news by following @DaVitaDoc on Twitter.

How the COVID-19 Pandemic Has Affected Kidney Care Sep 09, 2020

Show notes

According to Leslie Wong, MD, chief medical officer for the Nephrology Care Alliance (NCA) and practicing nephrologist at the Cleveland Clinic, during the pandemic, “…It's really incumbent upon us to stay united as health care providers. Remain positive, not just for each other, but for our patients, and make sure that we also help and celebrate when things go right.” Listen to this podcast, in which Sarah Carpenter interviews Dr. Wong on how COVID-19 has affected health care, in general, and kidney care, in particular. Dr. Wong discusses the impact of COVID-19 on clinician use of telehealth, the need to move care upstream to patients with chronic kidney disease (CKD), the adoption of value-based care models, the roles of patient education and predictive analytics in managing kidney care, and the communities of patients, families, caregivers, and nurses and other health care professionals. He also provides information on how NCA can help nephrologists address some of these challenges. For more information on NCA, including the latest news coverage, physician resources and thought leadership content, please visit https://nephrologycarealliance.com/newsroom/. Podcast Transcript: Sarah Carpenter (00:45): Hello, everyone. Welcome to the DaVita Medical Insights podcast. My name is Sarah Carpenter. I'm a teammate with Nephrology Care Alliance and I'm joined on the phone today with Dr. Leslie Wong, the Chief Medical officer for Nephrology Care Alliance. Hi, Leslie. Thanks for joining. Dr. Leslie Wong (01:00): Yeah, absolutely. Sarah, happy to be here. Sarah Carpenter (01:02): So I have a few questions for you. The first is, what has been your focus during the pandemic? Dr. Leslie Wong (01:08): Yeah, so while I am a chief medical officer for Nephrology Care Alliance, I'm actually, still a practicing Nephrologist at Cleveland clinic, so I kind of have a few different roles there. So it's been a very busy time as a physician leader. And in terms of interacting and orchestrating with teammates at DaVita, but also seeing my own patients and seeing the challenges that they've gone through as well as my colleagues at the hospital. Sarah Carpenter (01:42): Yeah. Thank you for sharing that there has been an emphasis on telehealth throughout COVID-19. How can clinicians better leverage telehealth to engage with patients? Dr. Leslie Wong (01:52): I think it's valuable to kind of step back and just think about how the pandemic kind of affected health care in general. I think especially in March and in April, when we really experienced the surge in the Northeast and really started seeing come to grips with how COVID was hitting the United States. I think that things that we thought could never happen or impossible, all of a sudden reality. And one of, again, the important things I think that everyone remembers and still it really preoccupies us today is how do you limit exposure to the virus? Not only for patients, but for health care workers. So I think the pandemic was really unique, at least in my medical career where, we're used to treating people with disease. Dr. Leslie Wong (02:48): We're not actually in the habit of thinking of how something that we're treating could actually affect us and actually harm us. And I know I've been really struck by all the testimonials, stories and collages of health care professionals, doctors, nurses, EMT, et cetera, they've actually succumb to COVID. Dr. Leslie Wong (03:09): So I think that, that's an important kind of background to acknowledge as we think about telehealth. So with this, really important need to limit exposure and transmission of the virus, the government enacted, these broad waivers across, various aspects of health care. But importantly that allowed clinicians in different categories of health care to be able to deliver and being reimbursed for telehealth services. So, again, not only to prevent transmission from an infection control standpoint, but also the reality is that, as people, even physicians were under quarantine. Or unable to use public transportation, but still with the need to have their medical conditions look after to speak with a health professional, telehealth is a technology that, that enables is really, really critical. Dr. Leslie Wong (04:16): So, being able to actually do that was and still is a tremendous benefit for our patients. Sarah Carpenter (04:23): Yeah. That's great. And what measures did Nephrology Care Alliance or NCA take to help with it? Dr. Leslie Wong (04:30): Yeah. So, One of the things that's important to understand is that prior to the pandemic, in order to participate in telehealth, there were very strict regulations and rightfully so. Privacy making sure that the data transmission was secure so that, people's information wasn't compromised. All those things were in place, but because of the extenuating circumstances with the pandemic, you really saw a kind of a broad relaxation of these guidelines. So it was actually permissible to use things like FaceTime and these kind of non-traditional platforms to deliver telehealth. Which actually would in some instances made it easy, but also, brought up a lot of other concerns and certainly larger health systems like Cleveland Clinic and other hospital systems already had telehealth systems in place, but had never had or utilized in the manner that this pandemic brought. Dr. Leslie Wong (05:35): So all of a sudden you had a lot more demand and then a lot more interests and then a lot more confusion about like, well, what's the right platform to use? What's the safest platform to use the most secure? And what's the most reliable? You can imagine a physician's office, a practice, just thinking about, well, listen, how... First of all, I don't have access to my patients. I'm now just processing all of these new telehealth waivers. I see the benefit of getting to patients, but it doesn't matter what I have. If they're not able to log in to my telehealth platform or they don't have say an iPhone, they can't use FaceTime. What do we do? So what we realized early on with... And where we thought NCA could really make a difference is that the Nephrologists were very much overwhelmed, not just with, processing information about the pandemic. But just all the different changes that accompany that. Dr. Leslie Wong (06:43): And so trying to actually figure out what is a telehealth platform to choose? What works? What are the features? I mean, these are things that there weren't enough hours of the day to do. We saw many Nephrologists that were just basically taking up either the first solution that came to them, or we're kind of inundated with a lot of advertisements. And had a lot of, different options that they didn't really understand it. And really felt like uncomfortable, committing to. So, I think the big thing that NCA did was that we recognized the need and we really pivoted the entire team to do a very broad, extensive search. And again, using a lot of the resources that we had within DaVita, kind of tapping on social strategy and other folks that look at that segment of this technology in the health care field, really try to identify and narrow down the field for our members. Dr. Leslie Wong (07:51): So I think over the course of about two weeks, we were able to meet with review, research, a limited number of telehealth vendors. And we were really struck and impressed by a company called Mend, they really had a... Not only a physician friendly interface, but also very patient friendly one as well. So we were able to negotiate a kind of a special rate and plan for a Nephrology practices so that they could quickly implement and sign up for a telehealth platform. And it start immediately taking care of their patients. And I think the big value for our members is that they could trust that not only they were signing up for something with no kind of, no strings, but really that we done our due diligence and research for them. Because really it was about how do we position them to start taking care of their patients as soon as possible. Sarah Carpenter (09:09): That's great. It sounds like a lot of work went into that. And so I think it's a really a value add. Speaking of patient care, how has COVID-19 brought forth the need for upstream care for patients with CKD? Dr. Leslie Wong (09:23): Well, unfortunately I think it's really highlighted some of the negative aspects of keeping people in isolation and away from the hospital. So, obviously we don't want the patients to be admitted to the hospital. We don't want them moving around visiting family unless it's absolutely necessary. And indeed, in many health care systems of hospitals, there were mandates that any elective surgeries, procedures, those things, those were not actually permitted for safety reasons. And furthermore, a lot of preventative health care interventions, vaccinations, cancer screening, those things were not considered essential. Dr. Leslie Wong (10:15): So patients were actually kind of discouraged. Or those things were not being scheduled. I think what really came to life was that, there wasn't a need for patients with chronic conditions, not only kidney disease, but heart disease, lung disease, diabetes know conditions that before the pandemic really required, close and regular follow up with physicians. And nurse practitioners in order for patients to remain healthy. Those visits also went down. And so what you saw was that it wasn't just the surgeries and procedures. It was the outpatient visits that really, really kind of almost went away. And some of those of course were things that could potentially in the short term be put off. But other things are really necessary care. And, I experienced that patients, even though they knew they needed to come in. They were actually scared because they didn't want to go to the doctor's office because that's where sick people were. Dr. Leslie Wong (11:22): They didn't want to go to the hospital because they were afraid of contracting COVID there. So I think what you saw from a health system perspective, is that the actual amount of energy and resources that we were spending on COVID went up tremendously, but everything else went down. And while that actually, on the surface looks like it's good that you're spending less resources on health care. I think universally, we think that, that's actually bad or that was bad because people aren't getting the kind of preventative care that they need. Dr. Leslie Wong (12:00): Again, as we discussed earlier, telehealth was a way that some of that need was met and we mitigate it to that risk. And in fact, at places like Cleveland Clinic and others, I mean the amount and volume of telehealth went up astronomically or exponential, I should say, compared to prior to the pandemic. But still, probably wasn't the same as before. I think as the situation changed, at least locally, where I practice, the in-person volumes quickly ramped up once kind of restrictions were lifted and locked hours and stuff became relaxed. Dr. Leslie Wong (12:45): But I don't know, if we absolutely know the end effect of that. So it's certainly something that is top of mind for many physicians, like the biologist who take care of patients with chronic conditions. And I should add that, one of the things that we think, and we know when we talked with our Nephrology Care Alliance physician leaders, we have a very highly engaged advisory board. And other physicians that we often speak to for input. And what they said was that the one thing that's really critical for managing and taking care of people with kidney disease is education. And had a discussion about how COVID is affected education for our children. But COVID really had a negative and dampening effect on disease education. Because, at the end of... That's like the first thing that goes because people don't think it's essential. And again, short of telehealth or the right type of equipment and connection from the patient it's really hard to do over the telephone. Dr. Leslie Wong (13:52): So I think those are things that we are very conscious of right now. I don't know if we know the effects yet because they're still in some degree ongoing. Sarah Carpenter (14:00): How do you think COVID-19, had an effect on conversations of value based care and that continued conversation of adoption and changing? Dr. Leslie Wong (14:08): Yeah, that's a very timely question Sarah. So one of the things that we do at Nephrology Care Alliance is, we're trying to help Nephrologists succeed with value based care, whether it's with government programs. Or with private health plans. And I think before COVID, kind of following the advancing American kidney health executive order in July, of 2019, it's kind of unprecedented excitement and conversations in the kidney community about the new government models. And speaking of what's called kidney care choices. So they're basically two programs, they're administered by CMS, that's centers for Medicare and Medicaid services. Dr. Leslie Wong (15:08): And specifically by something called CMMI, which is a center for Medicare and Medicaid innovation. And basically what the kidney care choices model are a weekly, the government sponsored innovation model for transforming kidney disease. So looking not only at the care of patients that are on dialysis, but importantly, moving up the screen to the care of patients with late stage chronic kidney disease. So we call stage four or five. So these are people that have kidney disease from hypertension, diabetes, and other causes, but they're not yet on dialysis. So it's kind of a really critical period where nephrologists can intervene. And as I mentioned, provide education that allows, kind of a shared decision making process. So, and we think that--And we actually have data, plenty of data, not just in the US but internationally that it's, that those interventions are done early enough during the.. In chronic kidney disease, patients are more apt to be transplanted. They're more apt to choose a home dialysis options and more apt to choose conservative measures and palliative care when that's appropriate. Dr. Leslie Wong (16:28): So I think that those models generate a lot of excitement, but what happened though, was around February or March, when the pandemic really started to come to the United States, there was... Everything was kind of put on hold, right? So, really the talk on the government side was about the emergency waivers, and all the different changes and including telehealth, but also other things in terms of how were we were kind of forced to change our daily kind of routines. And prioritize things differently. So I think there was a great deal of uncertainty if value based care, what the status was going to be. But know now is that as things have kind of... They haven't, again, we're not out of the woods by any means with, some of the resurgence in different areas in the country. But CMMI, did release finally kind of a delayed timetable, but basically they pushed the models back several months, but they were actually ongoing. Dr. Leslie Wong (17:44): So I think in terms of what NCAA is doing, how we're trying to enable value based care, it's kind of like the reset button has been pushed. So we're really actively engaging with a lot of the nephrology practices, nephrologists and other stakeholders, at a national level in terms of how they can participate, how they can succeed. And how to kind of navigate all the question marks that come with kind of large scale transfo…

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The Importance of Patient Education Aug 19, 2020

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“I would just really encourage folks to get upstream and get your patients the information early in their disease state, so that they can be more involved in their care and make good decisions for themselves,” says Josh Lowentritt, MD, a New Orleans nephrologist in private practice. Listen to this podcast, in which Martha Wofford, group vice president of DaVita Kidney Care, interviews Dr. Lowentritt on the importance of patient education, and empowering chronic kidney disease (CKD) patients to make active choices in their care. Dr. Lowentritt discusses his professional background, his passion for CKD education, like Kidney Smart, the patient’s perspective, the need for a CKD educator, the significant conversations related to diet, advice for nephrologists in providing education and the impact of COVID-19 on giving patients support. Podcast Transcript: Martha Wofford (00:40): Hello and welcome to DaVita Medical Insights Podcast. My name is Martha Wofford and I am a group vice president at DaVita Kidney Care, and I am excited to be joined today by Dr. Josh Lowentritt, he's a nephrologist from New Orleans. And just thank you, Dr. Lowentritt or joining us to talk about the importance of education for patients with chronic kidney disease. Dr. Lowentritt (01:03): Well, thanks. Martha Wofford (01:06): Yeah, thanks for being here. Dr. Lowentritt (01:07): Yes. Martha Wofford (01:07): First off, can you start by telling our listeners a little bit about your background and maybe why you're so passionate about CKD education? Dr. Lowentritt (01:15): Sure. So first of all, call me Josh, and I'm delighted to be here today to chat. I did all my nephrology training here in New Orleans at Tulane and finished up 2001. And I've been in private practice since then. So I'm doing hospital work, office work, I go to dialysis clinics. I still see my post-transplant patients after they get released back to me. And also do quite a bit of medical director work and work in population health and value-based care, which helps fill out my day. So, that CKD education, it's strange that it's such a novel idea. I was so lucky when I was in training. We actually had a dialysis CKD PD educator embedded in our clinic when I was a fellow. And so I always included CKD education when my patients would progress further along in their kidney disease, or make referrals to CKD education as appropriate, for patients to get the information they need. I've never imagined nephrology without having a CKD educator. And so I've just really enjoyed that association throughout my career. Martha Wofford (02:45): Oh, that's awesome. Yeah. I think not everybody probably had that advantage and that's a great way to shape your thinking about it. Just being core to what you do with patients. Maybe you can tell us a little bit more about what it's like from the patient's perspective, what their greatest needs are for education? And then when you encounter those needs, when and how you provide CKD education? Dr. Lowentritt (03:11): Sure. Kidney disease, it's intimidating. It's scary for patients. We're talking about real serious stuff, and at the same time, a lot of times patients don't know enough about it to even know what to ask. So my use of the CKD educator and the health materials and the Kidney Smart materials, that really helps round out what I need the patients to know so that they can be empowered to take care of themselves. Because as we know, we're dealing with a chronic disease state and a lot of the care is what people do on their own time, not when they're sitting in front of the doctor. So I think it's really critical that we provide education that is in a relaxed setting, not in front of the doctor. They should be able to feel like they can ask any question. And sometimes they're a bit intimidated to ask questions that might be personal, or they might think they're not really smart questions or something like that. And also because, when I'm talking to patients, there's the time limit. I have to keep moving on my schedule and patients may not remember to come back to ask the question if it slips their mind. So the educational piece is really critical in making sure patients understand what's going on with them. We're asking people to change their diet. We're asking people to manage chronic diseases, check their blood pressures, take care of their diabetes. We're asking them to pay attention to their feet. We're asking them to dramatically change their diet sometimes and they need support for that. So it's really a lot about empowering patients. Being sensitive to their needs. And really creating an educational space for them so that they can get the information and make the good choices for themselves. Martha Wofford (05:19): Yeah, that makes total sense. And I bet the dramatic changes to the diet down in New Orleans must be particularly painful for patients. Dr. Lowentritt (05:27): It's terrible. I have to tell people, "If you like it, you can't have it." Who wants to hear that? And, I'm not a dietitian. I have some thoughts about what you shouldn't eat. But I'm not able to quickly come up with substitutes. A trained renal dietitian, or a kidney educator who has experience in this, they are able to come up with good substitutes. Because obviously, we need people to have good nutrition. But again, I'm not trained for that. And I'm very happy to have folks on the team who are. Martha Wofford (06:04): Yeah. And one of the things that I'm really proud of is, as we overhaul the Kidney Smart curriculum, is we did a lot of work on diet and presenting different options for people so they could swap out something healthier for something that they really like in their diet. So that's a really easy part of the educational material to use for sure. Josh, what piece of advice would you have for other nephrologists who may not be utilizing CKD education or Kidney Smart with their patients today? Dr. Lowentritt (06:36): I would just ask nephrologists, "What is your goal for your patient?" If you want the best care for your patient and you feel like, as a physician you can do it all, by all means, keep doing it all. But, that's not the world that I live in. The world I live in is that kidney disease is a team sport. We need a whole team of people to take care of folks and give them the information they need so that they can make good choices. One of the most wonderful things about kidney care that I've enjoyed as a nephrologist is, I've always been doing care in groups. I'm meeting with my facility administrator and my nurses, my dietitians, social workers. But to be able to bring that upstream, bring that out of the dialysis clinic, why wait till someone has kidney failure to give them that level of care? Why would we not bring that upstream and give our patients the information and empower them to take care of themselves? Why would we wait for that? Let's get upstream. Let's not wait until they go to the dialysis unit so they can get a dietitian or they get dietary advice. Let's take care of that in a relaxed setting. What if we did that and our patients didn't need dialysis for another year or two, or maybe never, because they got the education they needed? Or what if they were able to pick the modality that's most important to them? Or even better, that we send them to transplant. When we get them set up at the transplant center and perhaps have a preemptive transplant if needed. That's what I would tell the nephrology community is if we really want to give the best we can for our patients, we need to include the team earlier and get much farther upstream than the dialysis unit. Martha Wofford (08:30): I love that Josh. I think you and I share, I know, a passion around trying to empower patients and really changing their trajectory, but what if really empowering them and getting them that information so that they don't progress is something that I know we're both spending a lot of energy, trying to make the reality for more and more nephrologists and more and more patients. Maybe if we just talked for a minute about what it's been like with COVID and how it's been to try to support patients and educate them and this period. Dr. Lowentritt (09:09): Sure. And of course, you know how COVID hit New Orleans pretty quickly, and it was really 10 weeks of an ordeal. Currently, we're the one part of the Louisiana where COVID is not flaring so badly after the initial, really it was a terrible 10 weeks. And fortunately, the whole population, especially the vulnerable patients really get it. They really need to say to themselves, they really need to be very careful when they leave their homes. So, I've asked my patients about that. In fact, in the last two days, I've talked to four patients about peritoneal dialysis, people that are new-starts. One patient who's already on hemodialysis. And one of the things I'm telling them now is, you don't have to come into a big group setting. You don't have to come in to the dialysis day clinic. You can do your dialysis at home and maybe reduce your risk of exposure from not having to get on transportation vans and not having to take buses and not relying on neighbors to bring you places. So I think, in the world, in our post-COVID world, we should be mindful of that. That, one of the ways we can help protect our patients is simply to give them their kidney care at home. So if that's education, the Kidney Smart education program currently is doing all telehealth, which is actually giving my patients much more attention than the previous era, when they would come in for meetings and meet in groups. They're actually getting a lot of one-on-one time with the Kidney Smart educator. And for my patients who require dialysis, why wouldn't we want to treat them at home where they can control the environment and get their care in the most comfortable setting possible? So I think post-COVID, it becomes even clearer. Oh, and don't forget, I live in a hurricane zone, and I tell my patients all the time, "If the hurricane comes, you pack up, you pack three days of supplies of peritoneal dialysis and you head out. And you don't have to set up dialysis when you get somewhere. And in our hurricane areas, I think they're also very important. It's pretty scary to rely on dialysis as a modality for life support, especially if you might have to evacuate for a hurricane or natural disaster. Martha Wofford (11:56): Yeah. I think we're such fans of the flexibility that PD offers to patients, and a hurricane's just another example of that flexibility and being able to pick up at a moment's notice. So it's been amazing. We, as I think you know, have about 1,500 educators across the country. And, as you were saying, in New Orleans, we've heard tremendous feedback from many of those educators that the transition to going to telehealth has been just a godsend for patients, where they weren't always able to access all of the health care system. But the ability to connect with an educator and then to follow-up and call them and ask all the questions that they have and get good answers, has been really important to helping them. And for many of them helping them start on PD. So, COVID's been a big push towards telehealth, which has been, in a way, a gift, sort of a silver lining, in the middle of this horrible crisis. So, we've definitely seen some of the advantages and we'll continue to offer Kidney Smart through many different modalities so that we can reach patients however they most want to be connected with. Whether it's in person with a group, or one-on-one over telehealth. So thanks for that. Any other closing thoughts that you would want to offer to our listeners? Dr. Lowentritt (13:25): Well, I would just really encourage folks to get upstream and get your patients the information early in their disease state, so that they can be more involved in their care and make good decisions for themselves. There's nothing better when a patient requires dialysis than a patient who is ready, trained, has an access, whether it's a peritoneal catheter, or a fistula. That they have already made dietary modifications. I like to joke, I have a small group of vegetarians out there among the meat-eating society. But, take advantage of the Kidney Smart program and get your patients involved in their own care. And actually, it allows us as physicians to give advice at a much higher level, and probably a more personal level than we might, if we're having to just really grind it out and have to educate on everything. If we have a patient who's ready for treatment when they need it, is someone who's aware of their transplant options. And someone who is involved in their care, they do a lot better over the long run. And that's my goal for my patients. Martha Wofford (14:46): Yeah. That's so well-said. Love it. All right. Well with that, why don't wrap up? And I just want to thank our listeners for tuning in and be sure to check out other DaVita Medical Insights Podcasts. And you can also find additional kidney care thought leadership in industry news by following @DaVitaDoc on Twitter. So thank you so much Dr. Lowentritt. Really appreciate, it was a pleasure to talk to. Dr. Lowentritt (15:11): Thanks Martha. I've really appreciated it. Thank you.

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Self-Care for Clinicians Jul 30, 2020

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“If self-care was important before the pandemic, it has become almost essential in everybody's life today,” says Usha Peri, MD, who is a DaVita medical council member and a SKY breath meditation instructor for the Art of Living Foundation. Listen to this podcast, in which Ryan Weir interviews Dr. Peri on self-care, with a focus on self-care for clinicians and during the pandemic. Dr. Peri discusses what burnout is and how to counteract it, what self-care means to her, how she became interested in the SKY breath meditation technique and why she became an instructor, and what tools she uses to help with her own self-care. During the podcast, she also demonstrates a couple breathing exercises that one can do in less than 5 minutes during a break in the day to unwind and reset before going back to work. Podcast Transcript: Ryan (00:40): Hello and welcome to the DaVita Medical Insights podcast. I'm your host Ryan. We're joined on the phone today by Dr. Usha Peri. Dr. Peri is on the medical council of DaVita and is a SKY breath meditation instructor for the Art of Living Foundation. Dr. Peri, how are you doing today? Dr. Usha Peri (00:57): Great. Thanks, Ryan. Ryan (00:59): All right. Dr. Peri, we're talking about self-care today and as we all know, there's a pandemic going on. So can you talk about the timing of this topic and why self-care for clinicians is so relevant right now? Dr. Usha Peri (01:11): Absolutely. Even before the pandemic physicians' burnout rates and health care professionals' burnout rates have been on the rise. Even though this word was coined back in the '70s, it has started becoming much more relevant recently with the rise of regulatory burden, as well as electronic health documentation burden that's being placed on the physician. Now, with the pandemic hitting, all of this has just gone exponentially high. Things are changing quite rapidly and they're asked to keep up with all the changes. As you know, regulations are changing, by the day, sometimes, and our telehealth visits, all of us had to transition to telehealth almost overnight. And the documentation rules around that keep changing as well. At the same time, our patients are also in this uncertain, anxious time. And so their demands on the health care professionals are higher and our ability to deal with the death and the grieving process, all of this is taking a huge toll on the health care professionals. If self-care was important before the pandemic, it has become almost essential in everybody's life today. Ryan (02:42): Yeah. And especially going months into this pandemic too. Dr. Usha Peri (02:47): Yes. And not knowing when it's going to end either, Ryan. Ryan (02:50): Right. Right. So self-care can mean a lot of different things to different people. What does self-care mean to you? Dr. Usha Peri (02:58): Right. That's a good question. Well, you're right. Anybody, who's human and living actually health care professional or not, is doing self-care in some form and fashion whether they call it that or not, right? All of us that are humans have to eat good food, hopefully, good, nutritious food, drink plenty of water, get a good night's sleep, and if things go well and we have a little extra time on hand, exercise perhaps, or spend some time with nature, walking, listening to music, et cetera. All of that would fall under self-care to me. I mean, that all sounds simple, right? And why do we even need to talk about it? Why podcast? Well, the challenge there is that the increasing demands that we talked about, we as human beings start cutting corners and start cutting into our eating time. What used to be an hour long lunchtime at one point in my own work day has now pretty much disappeared and exists in my car while I'm driving. Dr. Usha Peri (04:09): What used to be exercise time can go away if you have to catch up with your notes or do other important things for the family. What used to be sleep time can easily disappear, once again, when you're juggling multiple different tasks. And more importantly, if there's stress of negative outcomes, then it takes away your sleep. Even if you're in bed, you're running around not getting good quality sleep. So all of this starts taking a toll on your physical energy levels as well as mental energy levels. And then you slowly start feeling burnt out; emotional exhaustion, depersonalization and compassion fatigue, which is the three components of burnout. So now when we're in this stage, when we moved away from doing our usual things in a happy natural way, on to this vicious downward cycle of burnout, we have to do something extra to get ourselves back up at least to the baseline. Dr. Usha Peri (05:19): And that extra obviously is something that can recharge and rejuvenate us. And again, in our current society, it would be great if I can get this in the form of a pill. And if not in the form of a pill, something quick, that is not very time consuming, right? So while I was going through this journey in my own life, I stumbled upon this great breathing and meditation technique called the SKY breath medication. This is almost 15 years ago. And initially I used to do it as a hobby that made me feel great. And lately it has become a very essential part of my day. I spend about 20, 25 minutes of my time doing this and it recharges and rejuvenates me very naturally and very automatically. Ryan (06:10): So you mentioned that self-care isn't something new. It's gotten a lot of news lately but it's been around for a bit and you've been dealing with this subject for a while. So how did you originally get interested in this subject? Dr. Usha Peri (06:22): Sure. So, like I mentioned, these things happen very naturally but then I am a mother of two kids who are now young adults, 24 and 20. I have held many leadership roles in my company, including the immediate past presidency. And I've seen this company grow from a five employee to a 70 employee company. I'm a medical director on the medical council, married for 28 years. So I've obviously worn many hats. And in the process, just like I mentioned earlier, I've realized that I was cutting into things that are necessary to maintain a healthy body and a healthy mind. So during this time I stumbled upon this breathing technique. And now I come from a tradition of yoga. Growing up and going through medical school in India, I've taken great interest in doing some yoga postures and breath work. And I came here and all of that got lost in the business of daily life. Dr. Usha Peri (07:25): But then I rediscovered it about 15 years ago. Initially I was doing it for fun but later on, as life caught out and I was juggling all these different things, I realized that this is a great source of energy for me. It's a great source of winding down without having to have a drink of alcohol, which I've never been a big drinker at all but even social alcohol or just to wind down, which I used to do many years ago, at the doctors and parties, I've completely given up. And I realized that yoga, breath work and meditation are just much more powerful in helping relieve, let go of the daily stresses and to recharge and rejuvenate me. And not only am I now combating burnout but I've actually got an extra perk by practicing this which is peak performance. I realized that my mind can dive into the creative, intuitive sites of myself and come up with very beautiful problem solving. Dr. Usha Peri (08:29): For any problem solving we do need the creative and intuitive sites of our minds and brains active. And I noticed that doing this practice on a regular basis helps me do just that. So I'm actually a very sought after person in whatever field I choose to enter, right? Whether it's as a parent, spouse, at work, wherever I am, I'm considered a cheerful person who brings value. My patients love me because I bring that extra human element to the equation. And I have people who drive many miles across town to come visit with me as well, yeah? And then I realized that this is too beautiful of a tool to keep to myself. That I would love to share it with the world. So that's how I became an instructor five years ago. And now I teach this to youth as well as adults and health care professionals. Ryan (09:29): Yeah. Can you talk more about the tools that you use to help with your own self-care? Dr. Usha Peri (09:33): Sure, Ryan. So when I started out I took this workshop, a 10 hour workshop, called the happiness program or living well for health care professionals, which teacher the 20, 25 minutes take home breathing technique called the SKY breath or Sudarshan Kriya. The term that comes from yoga. And what it is it's a very deep involved breath work that allows us to clear up the day to day stresses. And allows us to get into a very meditative mode of mindset that allows me to just then slip into meditation. And meditation to me is effortless. It's not concentration, it's not focused. It's actually the ability to disconnect from our day to day activities. Dr. Usha Peri (10:24): We use our senses from the time they're up to we go to sleep, especially in this information overload, connected gadgets heavy world today. So that 30 minutes allows me to disconnect from all of that while I'm still awake, not when I'm sleeping and gives me a tool that's physiologically actually allowed for relaxation and disconnection and deep meditation, which is automatically recharging or rejuvenating. So yes, my tools are I do about five minutes of yoga stretches. The postures that are very well known. 20 minutes of the breath work called the SKY breath and followed by a 20 minute meditation. So total about 45 minutes to 50 minutes. That's all. That's how my day starts. And then the rest of the day, I feel like I can face anything that comes my way. Ryan (11:23): So these breathing techniques that you do is this something, I mean, while we're on the podcast and while people are listening, is this something that we can demonstrate now briefly? Dr. Usha Peri (11:34): Absolutely. So I won't be able to demonstrate the SKY breathing. For that you have to come to one of my workshops that I teach and learn. However, there are several breathing techniques that we can learn that can be done throughout the day intermittently, which I also do just to kind of like the reset button on the computer, right? You can pause. Actually we say "take a deep breath," right? It's similar to that. Except when done in a more scientific way, the way yoga has taught it to us over the year, then it has a much more physiologic effect on our body and allows us to reset that brain that's going a hundred miles an hour to give it that needed pause and bring it back to the center, right? So I'm more than happy to demonstrate a couple that everybody actually who's on the podcast can learn and use it throughout the day. Especially when you're feeling a little anxious or things seem chaotic around . Are you're ready for the demonstration, Ryan? Ryan (12:36): Yes I am. And for any listeners listening to this, is this something they can do while sitting, while standing? Dr. Usha Peri (12:42): Yeah, ideally it would be best to sit in a quiet corner with your spine erect. So when we start talking about yoga, we're talking about energy. We are energy bodies and we are gathering our energy up and when you're out and about doing our things, our energies are getting scattered and used. So when we are taking a deep breath, we're gathering our energy and we are balancing it. So to do that, just sitting in a quiet corner, closing our eyes, which takes away one of the outward focus, turning it inwards and taking a regular breath in and out, which let's do now. Let's take a regular breath in and out. And the first breath I'll demonstrate is called the straw breath. It's very simple like its name suggest. Take a deep breath through your nostrils and exhale through your mouth. It's like your mouth is now a straw. You're puckering your lips like a straw. Dr. Usha Peri (13:54): And you're blowing bubbles into the invisible water at the end of the straw like kids do. And now observe how you feel when you're doing it. Just take a couple of minutes to do this on our own and observe what happens in the body and mind. (Silence) Dr. Usha Peri (14:23): Taking long, deep breath. (Silence) Dr. Usha Peri (15:32): Observing any sensation that you may have in your body, any prospect maybe going through your mind. So put in your full attention on the breath. Breathing out through the closed lip like a straw. (Silence) Dr. Usha Peri (15:59): And then we get going with that last breath, relax your breath and continue to sit with your eyes closed (Silence) Dr. Usha Peri (16:19): Just observing how your body and mind feel and then when you feel complete, you may open your eyes. And if you're ready, I have one more breath to demonstrate. Ryan, are you ready? Ryan (16:41): Yeah, let's try the next one. Dr. Usha Peri (16:43): So this one is called the alternate nostril breath and as the name sounds, it's pretty intuitive. Actually the breath starts with a exhalation. With the breathing out through the left nostril and then automatically we breathe in through the left nostril and the left nostril is closed. We breathe out to the right nostril, breathe in through the right nostril. Close the right and release the left nostril. Then breathe out through the left and breathe in through the left. It's pretty intuitive. Whatever side you exhale, you breathe in, close that side of nostril, release the other and breathe out. And as we do this, once again, no rush, take your time, elongate the breath a little at a time and just watch how your body and mind feels. Okay. So let's get started with the thumb on the right nostril. The left nostril is open. Breathing out through the left, breathing in through the left. Dr. Usha Peri (18:14): Close the left nostril. Breathe out through the right. Breathe in. Close the right nostril, breathe out, breathe in. Close the left, breathe out through the right, breathe in, now out. (Silence) Dr. Usha Peri (18:53): Elongating the breath a little each time. (Silence) Dr. Usha Peri (19:16): Feeling the inhaling through your body and the relaxation that you feel. (Silence) Dr. Usha Peri (20:02): And then now you're done with that last breath. You may relax your breath and your hands. (Silence) Dr. Usha Peri (20:14): And hopefully you're feeling a little bit more relaxed in your body and your mind as well. And you may open your eyes. Ryan (20:34): Well, I think the analogy you used earlier about a computer restart button, I think that's pretty spot on after those breathing exercises. Dr. Usha Peri (20:43): Yeah. How long did you breathe, Ryan? Maybe four, five minutes at the most? Ryan (20:48): Yeah. I'd say so. Dr. Usha Peri (20:50): Yeah. And so four, five minutes in the middle of the day is not at all hard to find. And I do this in the lunch hour as well. Definitely use a few different breathing techniques from my two toolkit to unwind, reset, eat quickly, and then get back to work. Ryan (21:10): And can you talk about some of the science behind these breathing techniques? Dr. Usha Peri (21:15): Sure. Yeah. Yoga is a very ancient science. It's 6,000 years old. And the postures that we talked about, the breath work as well as meditation all have their roots and origins in yoga. And if you notice, Ryan, when we are angry, do you notice any change in your breath? Ryan (21:36): It gets quicker, right? Dr. Usha Peri (21:38): Yeah, it gets quicker, faster, and…

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Patient-Centered Care Jun 17, 2020

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With the increased use of technology, such as telehealth and remote patient monitoring, during the COVID-19 pandemic and the overall shift to electronic health records and predictive analytics in health care in recent years, caring for patients from an individual, human perspective, rather than from a numbers or data perspective, is becoming more important. How can patient-centered care have an impact on patients who have chronic conditions like kidney failure? Dr. Francesca Tentori, vice president of DaVita’s Outcomes Research and Patient Empowerment team, discusses this with Ben Brown, senior manager of DaVita Clinical Enterprise team in Denver, CO, in this podcast. While this podcast was recorded before the COVID-19 pandemic was declared a national emergency in the United States, listen now to learn more about how integrated and coordinated care is delivered in DaVita centers. Podcast Transcript: Ben Brown (00:28): Hello and welcome to DaVita's Medical Insights podcast. My name is Ben Brown. I am a senior manager in DaVita's clinical enterprise team based in Denver, Colorado, and I'm excited to be joined on the phone today by Dr. Francesca Tentori, vice president of DaVita's outcomes research and patient empowerment team. Hi there, Francesca. Dr. Tentori (00:49): Hi, Ben. It's good to be with you. Ben Brown (00:51): Well, I'm excited to have you with us today to talk about patient-centered care. Can you talk a little bit about how you define patient-centered care and what that means to you and how do you see it come to life in our dialysis centers? Dr. Tentori (01:04): Yes, definitely. So to start with, let me give you the definition that the Institute of Medicine has given us on what patient-centered care means. Obviously it's a term that we hear more and more. The official definition is providing care that is respectful of and responsive to individual patient preferences, needs and values, and ensuring that patient values guide our clinical decision. Dr. Tentori (01:35): And that's the part that is really exciting to me. So to me, patient-centered care means we provide care that aligns with each of our patient's needs, whether they're clinical or whether they are emotional. Obviously we're not always able to address all of their issues, but just awareness around what's important to each individual patient I think is a huge step. Obviously a challenging one, but I am very proud of the progress that is being made in this area, in medicine in general, and in dialysis in particular. Ben Brown (02:12): Thanks. I think that's great, and how do you see patient-centered care support our patients in a differential way? Dr. Tentori (02:19): So I think this is really, really important in a condition like kidney failure, and specifically patients on dialysis who are on a life sustaining treatment that they typically undergo three times a week if they're dialyzing in a clinic or every day if they're at home. Dr. Tentori (02:41): So their disease and their treatment is very much part of everyday life, and if we are honest, traditionally dialysis care has focused on improving clinical outcomes, achieving quality targets, which are absolutely very important, and results in better clinical outcomes. But the patient perspective was not really reflected or was not really always taken into account. Dr. Tentori (03:15): So in my mind having a structured way to account for the patient's wishes, their desires, to be more mindful that those need to be incorporated in the delivery of care makes a huge impact on the everyday life of our patients, just the fact that they feel valued and respected and listened to. There is a lot of literature and evidence supporting that it has a huge impact on their quality of life as well as potentially in clinical outcomes. Ben Brown (03:49): Yeah. And I think you make a really important point about DaVita's patient population and what it actually looks like to come to life in one of our centers where the schedules and operations can be very regimented and occasionally appear a bit overwhelming with so many patients being managed at one time. Ben Brown (04:11): So how do DaVita's care teams effectively deliver patient-centered care? And maybe you could describe what that process actually looks like and what it has meant for them in terms of outcomes. Dr. Tentori (04:24): Yes, absolutely. So all of us who have been in the clinic know that it's a hectic place. Everybody is running around always trying to do the right thing for patients, but sometimes the communication and integration of the different activities is not ideal. Dr. Tentori (04:44): One of the basic principles of patient-centered care is the coordination and integration of care. And that is to, across health care providers so the dialysis center communicating with other health care providers as well as within the clinic. We obviously have being able to really work and focus on the communication and integration within our clinic. And we want to make sure that we optimize a communication across the people who interact with patients. Dr. Tentori (05:22): So, starting with patient care technicians who have the most interaction, nurses, social workers, dieticians, physicians, we want to make sure that they're all aligned and aware what's going on with a given patient in a given time in order to be able to better respond to those needs, whether with changes in the clinical care that's needed or with other types of support. Dr. Tentori (05:52): The way we have implemented this at the DaVita clinic is starting to having daily meetings of the people who on the floor interact directly with the patients. So you can think typically of patient care technicians, nurses, if it's the week where the social worker are also interacting with that specific patient. Dr. Tentori (06:19): And that's the place where they communicate whatever is new with the system individual. That is no need obviously to cover every single person who's been treated on the floor that day. But the patients who might present with something new or with a new need. Dr. Tentori (06:36): And then the next step is to bring those information or the things that cannot be addressed immediately that day to a core team meeting. And that is a meeting for the leads of the care team, including physicians, nurses, etc. And again, the idea is that problems get escalated so that decisions can be made that address the individual needs of the patient who have come, we have become aware of as we interact with them on the floor. Dr. Tentori (07:15): And obviously one thing that I would like to stress is the importance, not only of communicating what the certain patients specific needs are today, but where we see the real importance is for the clinical team to together make decisions and come away from these meetings with a common understanding of what the care plan or any activity relating to that specific patient is going to be moving forward. Ben Brown (07:46): I think that's so important, Dr. Tentori, that when the whole team comes together to discuss those, the most important issues that a patient is facing and have the right plan in place that brings the patient's needs and wishes into mind is when we really see success and the right outcomes that we're striving for at DaVita. Dr. Tentori (08:09): Absolutely. Ben Brown (08:10): Thanks, Dr. Tentori. I think that insight is incredibly helpful for our listeners. What type of results have you seen tangibly come from this patient-centered care approach that you just mentioned? Dr. Tentori (08:22): Yeah, actually we have been able to measure this. We conducted this initiative in 400 DaVita clinics and we were able to really see an impact on measurable outcomes. If you think of hospitalization, for example, as one of the things that are most important, definitely to patients. I have never met a patient who wants to spend time in the hospital as well as from a dialysis organization perspective, obviously the logistics of a patient not showing up for dialysis and then having to make up for treatment or the treatment that's received at the hospital, not being ideal. Dr. Tentori (09:01): That's definitely something that we have put a lot of energy into and when we looked at hospitalization, at the center that participated in this initiative, there was significant and meaningful reduction among patients treated with three times a week in center hemodialysis, as well as in PD patients. Dr. Tentori (09:24): So we were able to see a full impact on daily tangible clinical outcome that's important to patients. To me even more importantly is that this type of initiative, so implementation of patient-centered care in a structured manner was really well received. Patients found that they were being listened to. Dr. Tentori (09:49): One concern obviously was that clinical staff would feel overwhelmed and that it was too time consuming and we have not received that pushback at all. And physicians as well thought that they were receiving better information and more coordinated information. So I think that overall it was really a win-win both for patients and the clinical staff. Ben Brown (10:13): That's awesome to hear and I know it's great not just for our clinics, but to share what impact it's really had on our patients. Dr. Tentori (10:21): Absolutely. Ben Brown (10:21): And for our patients, one of the most important and most difficult decisions they have to make is where they will receive their dialysis treatment. That may be in a dialysis center or within their own home. However, when as you mentioned, a patient goes to the hospital, which no one wants, their risk of being able to maintain treatment on their preferred modality increases significantly, especially for our patients who treat at home. Can you talk about how patient-centered care affects those patients treating at home and their quality of life? Dr. Tentori (10:53): Yeah, absolutely. I think that, well you brought up I think two separate issues. One is how disruptive hospitalizations are and the risk that might result in a switch in modality specifically for patients who are being treated at home to them go to in-center hemodialysis. The benefits of a patient-centered care approach is that we are all aware of what's happening individualized. We are also more aware of what the barriers might be and we are better equipment to address them. Dr. Tentori (11:32): So for example, if a patient goes to a hospital and they're not able to receive PD while they're in the hospital, we are more aware that that was the case. It might very well be that the patient needs a few sessions of in-center hemodialysis, but we are better prepared to facilitate the transition back home. Dr. Tentori (11:55): The other topic I think that you brought up is the perception and experience of care for those patients to dialyze at home and while there's so many positive aspects, the flexibility, the fact that they can maintain their lifestyle, they can remain employed, et cetera, et cetera. For some patients, dialyzing at home can also be an isolating experience just because they don't have the social interactions with our other patients and clinical staff three times a week as it happens with in-center hemodialysis patients. Dr. Tentori (12:33): So I think that more intentionality, and being more willing and really invested in understanding what's important for a person who is dialyzing at home, as well as what are the obstacles. Has something happened at home that we would not have otherwise being aware of that is making it harder for that person to dialyze at home and can we support them in any way? Dr. Tentori (13:01): I think that's really what's valuable for this process is not only looking at the clinical parameters, which obviously are very important, but in the case of an older person doing peritoneal dialysis at home. It might be very important for us to know that that spouse is now in the hospital for other problems and so suddenly the responsibility and the burden of the treatment is all on our patient. Those are the kinds of things that can help us, as clinicians, better support that patient and I think really, really have an impact on the experience of care, as well as the overall quality of life for patients dialyzing at home. Ben Brown (13:49): Thanks, Dr. Tentori. I think it's so important what you just said about how patient-centered care can help patients receive dialysis on their modality of choice, whether that's in home or at the dialysis center. For our podcast listeners who are clinicians, what are one or two takeaways about patient-centered care you would like them to leave with and do you have any recommendations for how they can implement this approach into their own practice? Dr. Tentori (14:17): Yes. Thank you, Ben, for that question. This is obviously a topic that I have a lot of passion about. I also think that the term patient-centered care is a little bit scary and sometimes we don't really understand what it means. Dr. Tentori (14:33): Really to me the most important message is something that each of us interacting with patients can implement every day. The big first piece is do we know what the needs and the preferences for our patient, that specific individual patient is today, and are we intentional, are we mindful in making sure that's the case? So, do we ask that question? Dr. Tentori (15:04): And then the other piece is do we share whatever we have learned about that specific individual? Do we share that with our colleagues, with other members of the clinical team so that we're all on the same page and then we can come up with a plan that will address that need? Dr. Tentori (15:25): And I want to stress that for many of our patients who have multiple comorbidities, we are not going to be able to address all of their needs or solve all of their clinical issues, but just the awareness that this specific problem—the fact that Ms. Jones has been, was admitted to the hospital yesterday is important. And just having that awareness, I think can really make a huge difference in the type of care that we as a dialysis community deliver to our patients. Ben Brown (16:00): Dr. Tentori, I think that is a great message for all listeners, clinical or non-clinical, to be able to take away and think about how patients not just receive their treatment, but how they feel cared for. And so I am really happy that you are able to join us today and for our listeners, if you're interested in learning more, please check out the DaVita Medical Insights podcasts that are available online today.

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Patient-Centered Care Jun 17, 2020

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Kidney Care Transformation: A Global Perspective Mar 11, 2020

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Innovations in nephrology are taking place as the importance of kidney health is emphasized globally. Listen to this podcast, to hear how kidney care is transforming around the world, with insights from clinicians who share a passion for innovation: Jeffrey Giullian, MD, chief medical officer for DaVita Kidney Care; Janet Cowperthwaite, director of clinical operations for DaVita International; Sam Kant, MD, nephrology fellow at Johns Hopkins Hospital; Szymon Brzosko, MD, chief medical officer for DaVita Poland; Mandy Hale, vice president of nursing for DaVita; Francesca Tentori, MD, vice president of outcomes research and patient empowerment for DaVita, Wisam Al Badr, MD, chief medical officer for DaVita Saudi Arabia; and David Roer, MD, vice president of medical affairs for DaVita Integrated Kidney Care. Listen and read more DaVita Medical Insights here. Podcast Transcript: Ryan Weir: 00:32 Hello, everyone. This is Ryan Weir with the DaVita Medical Insights Podcast. The importance of kidney health is emphasized globally. I've recently caught up both in person and over the phone with nephrology clinicians from around the world to gather an international perspective on kidney care transformation, innovations they're looking forward to seeing within the next decade and more. Ryan Weir: 00:52 In this podcast, we'll hear from clinicians in Poland, Saudi Arabia, England and the United States. We asked Dr. Jeff Giullian, chief medical officer for DaVita Kidney Care; Janet Cowperthwaite, director of clinical operations for DaVita International; and Dr. Sam Kant, nephrology fellow at Johns Hopkins Hospital, what they believe is the next big thing that will improve kidney care in their country. Let's hear what they had to say. Dr. Jeff Giullian: 01:23 We are living through a time of great innovation expansion within kidney care today. I see really a few key innovations coming down the pike that will, I believe, likely change the way that we deliver care in the U.S. and really perhaps across the entire globe. So the first is, within chronic kidney disease, we are seeing innovation in artificial intelligence and predictive analytics, which will help caregivers segment patients based on their risk for renal progression. Dr. Jeff Giullian: 01:52 Second big area is, for patients with end-stage kidney disease, we're seeing innovation that enhances their ability to choose a dialysis modality that best meets their personal needs. This includes items such as home-remote monitoring to all the way to new devices for home dialysis. Then the third thing is that there are mechanisms now to increase the number of kidney transplants. This category really includes everything from paired and chain donations, but also new types of organs and implantable devices that are really a little bit more distant into the future, but they are exciting nonetheless. Ryan Weir: 02:28 Janet Cowperthwaite Janet Cowperthwaite: 02:30 From my perspective, I think it's about patients' engagements and activation. Engagements in their treatment and choices, but also how we run and provide the services, and in other aspects involving them in things like in safety and quality forums within the clinic. Ryan Weir: 02:49 Dr. Kant Dr. Sam Kant: 02:51 I think one of the biggest things is that we so far only relied on one or two blood tests when it comes to diagnosing kidney disease and managing things. I think the emergence of biomarkers, especially, whether they're serum or a urine, any biomarkers, it will probably help us elucidate what kind of acute kidney injury someone has or what kind of disease you know is afflicting the kidneys. I think that would be something that you would see increasing utilization all throughout. Definitely I think has a lot of scope going forward. Ryan Weir: 03:26 Dr. Szymon Brzosko, chief medical officer for DaVita Poland and Mandy Hale, vice president of nursing for DaVita based in the U.S., told us about the one thing that could help improve health care in their respective countries and worldwide. Dr. Szymon Brzosko: 03:41 In Poland, I really would like to see more home renal replacement therapy options being available for patients. Especially I'm thinking about more peritoneal dialysis, it is a valuable one. We have many kinds of treatment options available in my country, but in parallel existing regulations and organizational issues with qualifying patients for being active on the waiting list a problem for potential donor or even social acceptance of these methods is still too low and this is the area where I would like to see you know, improvements and by that probably allowing patients to live better with the disease. Ryan Weir: 04:38 Mandy Hale Mandy Hale: 04:40 I'm going to answer the question as one thing that can improve health care in my community, my country, my world with two answers and that is awareness and preventative care. I think it is so important that, we, as nephrology clinicians, continue to put emphasis on the importance of creating awareness for individuals when it comes to chronic kidney disease, which is so many times and referred to as a silent disease. We must help people understand the risk factors and what type of tests and intervention can help when we refer to CKD and we must provide access to that type of care. I see a whole lot of focus on thinking creatively through helping patients access care or helping individuals understand the risk factor. For me that is just the largest hope I have that we can help read through the presence of chronic kidney disease. Ryan Weir: 05:41 We wanted to hear about the one innovation in kidney care these clinicians believe would create a better future for people with kidney disease. So we asked Dr. Francesca Tentori, vice president of outcomes research and patient empowerment for DaVita, Dr. Wisam Al Badr, chief medical officer for DaVita Saudi Arabia, Dr. Giullian and Dr. Kant for their perspectives. Dr. Francesca Tentori: 06:03 I'll be honest that this is the first time in my life as a nephrologist that I have seen something I'm super excited about. At the last ASN, for example, there were several new dialysis machines and just in general, technology platforms that I thought were really “cool and exciting” and I really envision them to come to fruition sometime in the near future and I think those are good to make a huge difference for our patients. Ryan Weir: 06:39 Dr. Al Badr Dr. Wisam Al Badr: 06:41 One of the most important innovations that we are looking at in the nephrology community today that would bring in the best results for our kidney population is a better screening measure for early detection of kidney failure. Currently, we rely on a blood test including the creatinine and the estimated GFR, but it presents the disease quite late. Finding this measure that presents an early detection of kidney disease would be the best innovation available. Ryan Weir: 07:25 Dr. Giullian Dr. Jeff Giullian: 07:27 I don't believe that there's one single innovation that's the silver bullet at least until we have the ability to provide true regenerative medicine. Rather, I think it's a combination of innovations that will help us slow the progression of kidney disease and then provide many more options for replacing renal function in the event that we can't halt progression of CKD. Ryan Weir: 07:48 Dr. Kant Dr. Sam Kant: 07:50 That's a very interesting question. I think one of the biggest things as a doctor looking after patients who have already undergone transplants, I always feel immunosuppression is necessary, but there's also associated with a lot of side effects and is expensive. There's a big push from centers all over the world to come up with ways by which we can avoid immune suppression all together. They're talking about various STEM cell infusions or modified immune cells infusions, to be more exact. That might help and look very promising in evading immunosuppression all together once patients are transplanted. I think that's of the things I'm really looking forward to. I really hope it works out and it’s certainly I've been going on and on about it, I think it would be a complete game changer. Ryan Weir: 08:42 Dr. David Roer, vice president of medical affairs for DaVita Integrated Kidney Care, Dr. Giullian and Dr. Brzosko provided their thoughts on what the kidney care community is doing well and could impact the rest of health care. Dr. David Roer: 08:55 I think the one thing that the renal care community can do and help as an example for the broader health care community is using robust analytics to organize and develop highly effective and efficient care delivery systems through integrated kidney care team. The kidney care community has been at the forefront of collecting important clinical demographic and financial metrics. Using this information to efficiently and effectively care for patients with chronic kidney disease will be essential in driving towards the goal of reducing chronic kidney disease and slowing the progression of chronic kidney disease. Ryan Weir: 09:43 Dr. Giullian Dr. Jeff Giullian: 09:45 The kidney community in the United States is working to break down silos and reduce fragmentation and care. Now, we're still very far away from achieving that goal. However, as we do improve care coordination and data sharing, I believe this will have a major positive impact on the care that we provide to our patients and will serve as a model for the rest of health care. Really, along these same lines, nephrologists and kidney care providers like DaVita are leading the country in integrative care and value based reimbursement from the ESCOs which were the ESRD or ESKD seamless care organizations to CSNPs, chronic special needs plans to other integrated care arrangements. Kidney care is ahead of the rest of health care in the movement away from volume-based payments and towards value-based payments and I'm very proud of the role that DaVita and our nephrology colleagues have played in this arena. Ryan Weir: 10:37 Dr. Brzosko Dr. Szymon Brzosko: 10:39 First of all, I'm really impressed how the nephrology community was able to take it on and successfully took advantage of the power of social media and other internet platforms for education and nephrology education, sharing knowledge and connecting the kidney community across the world. And by saying this, I mean including students, doctors, medics, scientists and organizing many activities to join like journal clubs, like NephJC to mention, which I really enjoy very much, Neph Madness by American Journal of Kidney Disease, a nephrologist podcast where our community's very active, e-learning activities like NTDS by ASN and smart use of social media like Twitter. It allows people to create a personal and professional social media network. When you start, you actually choose who you follow, it can be really enriching your expert knowledge and experience whatever professional career step you are in and actually many smart people are actually there. Dr. Szymon Brzosko: 11:54 Having my Twitter as an example, these people are willing to discuss, share and talk. Including DaVita teammates, like probably well known for all of us, Dr. Provenzano, Dr. Mahesh Krishnan or CMO for DaVita International, Dr. Partha Das. They are all present there. Oh yes, and to mention our current CMO for DaVita Kidney Care, Dr. Jeff Giullian, is also there. So indeed sometimes it is the field where you can interact with people you tried to contact during, for example, a conference but fail as they are busy or you are too, too far in the line. That's an approach that for sure, I would say, makes nephrology great again. Dr. Szymon Brzosko: 12:39 But probably even more impactful to patients, I would like to mention how the kidney community is supporting educating patients and the patient empowerment idea, and nice examples of that is taking into consideration patient oriented outcomes as an endpoint in nephrology to try it out. This is so much an essential part of the change I see and feel is getting real value in the care we deliver to patients. It’s called patient-centered care, where after explaining the problems, current options, order for treatment, then patient goals, values and patterns to the very center stage. Ryan Weir: 13:30 How do we see the nephrology community changing in the next year? What about within the next decade? Mandy Hale, Dr. Tentori, Dr. Roer and Dr. Kant provided their thoughts. Mandy Hale: 13:41 I'm really excited about the transformation of nephrology care that I think we can expect over the next year and of course well into the next decade. There's so much focus and energy right now around, I would say, three things that I think are going to look a lot different. The first one is preventative care and the focus on really preventing and delaying chronic kidney disease, so I'm so excited for individuals who may have access to care who didn't before or access to different types of care to really look at preventing the need for further intervention as kidney failure progresses. That's one exciting thing. Mandy Hale: 14:27 Secondly, I'm very excited about the focus, the intentional focus, around increasing the presence of home dialysis, home therapies, both peritoneal dialysis and home hemodialysis can be life changing for patients, both through improving their outcomes and their quality of life and the way they feel, but also will really dramatically change the way that nephrology care is delivered. Mandy Hale: 14:56 Then thirdly, I'm also excited about the focus on transplants. I really look forward to further changes, particularly here in the United States that will help make transplant easier; easier for patients to obtain, easier for donors to donate and the increased coordination that will resolve with dialysis and kidney care providers and transplant facilities. Ryan Weir: 15:22 Dr. Tentori Dr. Francesca Tentori: 15:24 I didn't know that it's necessarily changing, but I think there's going to be more and more emphasis of the need to integrate a kidney care across the continuum of the kidney disease spectrum. So, from CKD into dialysis to transplantation towards end of life, integrating all of the stats. That means better communication across clinicians and providers. That's something that is really gaining traction and people are interested in. Ryan Weir: 15:58 Dr. Roer Dr. David Roer: 16:00 Let me start with the second question. I believe, as a nephrologist and part of the renal care community, we would all agree that improving the care of patients with chronic kidney disease to reduce the number of individuals suffering from chronic kidney disease and focusing on a cure rather than on renal replacement therapy is the ultimate goal. This is an exciting time in nephrology that this goal may be achieved within the next decade. The prevalence of chronic kidney disease in the United States is approximately 15% and two thirds of those suffering from chronic kidney disease and end stage kidney disease has concurrent comorbidities of diabetes, hypertension and cardiovascular disease. There are accelerating advances in innovation in the treatment of patients with chronic kidney disease. Recent research has shown evidence that new pharmacologic treatments for diabetes can slow or stop the progression of chronic kidney disease and reduce the cardiovascular risk, mortality and need for dialysis. Dr. David Roer: 17:10 The advancing understanding of the pathophysiology of chronic kidney disease and precision personalized medicine will hopefully change the natural history of chronic kidney disease. The first part of your question, “how do I see nephrology care community changing in the next year?” With…

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Nine Questions with Dr. Jeffrey Giullian, Chief Medical Officer for DaVita Mar 03, 2020

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Jeffrey Giullian, MD, is passionate about his new—as of Jan. 1, 2020—role as chief medical officer (CMO) for DaVita Kidney Care. Listen to this podcast, in which Halie Peddle interviews Dr. Giullian on his priorities and vision as CMO for DaVita. He gives us some personal background on why he pursued a career as a physician, specifically in the field of nephrology, and what originally brought him to DaVita. Dr. Giullian also discusses his views on kidney care-related innovation and how kidney care is leading all of health care in the shift from volume- to value-based care. Listen and read more DaVita Medical Insights here. Podcast Transcript: Halie Peddle: 00:33 Hello, everyone. This is Halie Peddle with the DaVita Medical Insights Podcast. Today we're joined by Dr. Jeff Giullian, newly announced chief medical officer for DaVita Kidney Care. Dr. G., Thank you so much for joining us. This is our first opportunity to sit down with you since you started your new role. I'm excited for our listeners to get to know you even better and hear your thoughts on innovation in the field of nephrology. Dr. Giullian: 00:57 Well, thanks Halie. I'm really excited to be here and share some of my passion for taking care of patients with kidney disease. Halie Peddle: 01:03 Great. Well, let's dive right in. Lots to talk about today. I want to start off just a little bit more personal. Would love to hear what made you decide to pursue a career as a physician? Dr. Giullian: 01:16 That's a good question. Believe it or not. Growing up I was going to be a lawyer. Don't tell any of our lawyer colleagues. They won't believe it. Freshman year in high school, I got a chance to shadow some lawyers. And I have to tell you, I realized that day, the law was not for me. I didn't really understand what they were doing, and it really didn't appeal to me. Dr. Giullian: 01:36 And right after that I had some biology classes where we were actually doing anatomy and physiology, and somehow it just clicked. The timing was right. And finally I found something that I could really sort of sink my teeth into from a passion standpoint. And that was the human body, the physiology of the human body. And from that point on I was dedicated to becoming a physician. Halie Peddle: 01:56 And of all the fields you could have chosen, what made you choose nephrology? Dr. Giullian: 02:00 Yeah, that's another, I think, funny story, or one at least I like to tell. When I was a medical student, nephrology was the last possible thing that I enjoyed doing. It wasn't something that I particularly understood very well. It wasn't something that really captured my heart or my interest. And turns out that the very first month of internship, I was given a chance to spend about five weeks with a couple of nephrologists. And by given a chance, I went kicking and screaming. It was the elective that was given to me, not the elective that I asked for. It turns out I absolutely fell in love with the physicians I was working with, the patients that they were taking care of, the pathology and the physiology that goes along with kidney disease. And I was hooked from that point forward. Halie Peddle: 02:46 And then tell me what brought you to DaVita? Dr. Giullian: 02:48 So I was in clinical practice here in Denver. My wife and I, we're both from Colorado. We're both natives. I met her while I was in school in Nashville. She and I were, I was in training at Vanderbilt, and she was on faculty at Vanderbilt. And we had every intention of staying at Vanderbilt and staying on faculty. In fact, I was going to practice transplant nephrology and general nephrology there. Dr. Giullian: 03:12 And then fortunately we had a little gift that arrived, my daughter, and we realized very quickly that if we didn't want to spend every vacation flying home from Nashville back to Denver to see all the grandparents, if we actually wanted to take trips on vacation, we'd be better served coming home and being in Denver. And so I came home, and I went into practice here in Denver. Practiced nephrology, general nephrology and transplant nephrology, just about 15 minutes south of downtown. Loved it. Loved every minute of it. Loved my patients. And during that time became more involved with DaVita, doing some work as the group medical director where I helped other medical directors in the center part of the country with clinical outcomes. Dr. Giullian: 03:59 And as I got more and more involved with DaVita and started spending more time at DaVita and a little bit less time with my practice, it became evident that I needed to choose one or the other. And so when I had the opportunity to come to DaVita full time, just about four years ago, I jumped at it. Halie Peddle: 04:14 And now as chief medical officer, what aspect of the role are you most excited about? Dr. Giullian: 04:19 Gosh, there are so many aspects. I'm really pinching myself every day that I get to wake up and really serve our physician partners, serve our village, and most importantly serve our patients as chief medical officer. Dr. Giullian: 04:33 And really, I have three big priorities. The first one is holistic care for our patients. And what that means is providing kidney care wherever patients are on the entire spectrum, whether they have early CKD, more advanced CKD, whether they're considering dialysis because they've advanced to the point that their kidneys are not working any longer, or they're on dialysis, or they're waiting for a transplant, or have gotten a transplant. That's really my number one goal is to provide holistic care to that entire group of people. Dr. Giullian: 05:01 The second is to really double down on the foundation that my predecessor Allen Nissenson put into place, which is a focus on patient safety, clinical quality and patient experience. Dr. Giullian: 05:12 And then the third is forging a future of innovation so that we can in time truly reduce the global burden of kidney disease. Halie Peddle: 05:19 There's tremendous innovation in our field right now and as we look to the future. So I'd love to ask the next couple of questions on that topic. So how would you say DaVita defines innovation? Dr. Giullian: 05:31 Well, for DaVita, continuous improvement is in our DNA, and innovation, I think, takes continuous improvement, really to the next dimension. DaVita pushes for what health care can be, not necessarily what it is right now. And that's especially true around transforming the care that we provide to improve quality of life for our current patients and certainly for our future patients as well. So in that context, I think innovation takes forms. And we are driving innovation by improving care delivery, by developing cutting edge technology, and by advancing new models of care. Dr. Giullian: 06:06 We've also really focused heavily on the science of implementation. So this is a discipline of science that focuses on applying research findings and evidence based interventions to routine clinical practice. And this is really part of how we innovate. And the bottom line is we are committed to helping patients manage their kidney disease, really at all stages from, from early on as I mentioned, so that we can delay the progression of their disease, and to those that are later on so that we can ultimately, if they do need dialysis, we can help them in that transition. We can provide them the greatest possible health during all of that. And importantly, we can help them seek a kidney transplant. Dr. Giullian: 06:46 So really regardless of where somebody is on that continuum, I think that at DaVita, and certainly within the office of the chief medical officer, we really embrace our patient's unique lifestyle needs. And we've developed a patient centric care model. And this is all, I believe, due to the innovation that has been put in place. And we believe in offering the right treatment for the right patient at the right time. Halie Peddle: 07:08 And for a patient with kidney disease today, how do you see innovation showing up for them? Dr. Giullian: 07:13 Yeah, so that's a good question. As I think about sort of my own patients, patients that I've cared for in my career, I think it really comes down to giving each individual the best possible experience and the best chance for improving their health. And so I think patients want to know that they are cared about as well as being cared for. And that's really something that I've tried to incorporate into my clinical practice back when I was in practice. Dr. Giullian: 07:38 So for anybody helping care for patients that have a chronic disease, whether that's kidney disease or anything, it means providing holistic care, care for really the whole being. And that's greater than just kidney care for us. It also means helping them with the healthy lifestyle, helping them stay out of the hospital, fewer days in the hospital. At least the way I think about it means more moments at home with their family and with their loved ones. Dr. Giullian: 08:04 And so, we live in an era now where we can personalize care. We no longer are confined to sort of a one size fits all treatment options. We can really help optimize care for any individual. And so I think that's what innovation looks like to our patients. Halie Peddle: 08:20 Yeah. And now if we want to look just a little bit broader at the nephrology community as a whole, what do you think the focus is right now in terms of innovation? Dr. Giullian: 08:30 The kidney community as a whole has focused on improving safety, decreasing hospital admissions, reducing mortality rates through implementation science, which I mentioned earlier, and specifically by leveraging data from the entire population. Research has demonstrated ways that we can implement quality improvement activities really at scale. And I think this is what the community has been focused on as a whole, and we are all to transform the patient experience, provide broader access to care, improve outcomes, and ultimately reduce costs. That's how we provide value. Dr. Giullian: 09:04 The constraining factor has really been reimbursement, which has been stagnant for more than a half a decade. And the dialysis industry, as an example, provides onsite social work. It provides insurance counseling, care coordination, gosh, you name it, nutritional counseling and a lot more to help provide holistic care of patients. But the ability to innovate, at least in the past, has been constrained by regulations, and to some extent, reimbursement has not kept up with the increasing needs of our patients. Dr. Giullian: 09:34 Fortunately, I would say that the kidney community has achieved very high levels of health equity. And this is really due to a tremendous amount of work by members of industry and the community as a whole. And that's health equity and access to safe, effective treatments and continuing, I think the entire community is looking towards new models of care to do even more for kidney patients. Dr. Giullian: 09:58 DaVita believes strongly, and I certainly believe strongly, in equitable access to care from early CKD identification all the way to nephrology care and ultimately to access to kidney transplants. Halie Peddle: 10:10 So it seems like innovation at an industry level, and even as we look at it from a DaVita standpoint today, it's focused not only on that full continuum of care but also how that shows up day to day. But when we look to the future, 20 years from now, what big innovations do you think could change the way that care looks like? Dr. Giullian: 10:30 Boy, it's so exciting to think about 20 years from now because I think the landscape for kidney patients will look very different than it looks today. And I was recently remembering that I saw my very first kidney patient as a medical student just a little over 20 years ago. I will probably retire, God willing, sometime in approximately 20 years. So I'm in the middle of my career, and what I can say is that I think things will look very different in the year 2040 than they look in the year 2020. That will include things between now and then like wearable dialysis devices, implantable devices that can go inside the body and work like a kidney, but that are not necessarily biologic. They're technology based. And there will certainly be new options for kidney transplants as well. So I think over the next 15 to 20 years or 25 years, we will see a complete revolution in the way that patients with kidney disease are cared for. And I'm hoping that we will even begin to see the beginnings of regenerative medicine, the ability to actually go in and do things to repair kidney damage for those patients that have chronic kidney disease so that they don't progress on to needing dialysis. Halie Peddle: 11:41 Very exciting. And I want to switch gears just a little bit, and I'd love your thoughts on this, Dr. G. Many people within the health care community are talking about kidney care because it's thought to be the tip of the spear when it comes to value-based care. Why do you think kidney care is leading this conversation? Dr. Giullian: 11:59 Well, first off I think it's worth mentioning first and foremost that it's really an exciting time to be part of the kidney care community. There's a lot of attention on us now that we didn't necessarily have in the past. In fact, I would say never in my career have I seen so much emphasis on finding new ways to care for really what I think of as one of the most vulnerable patient populations in our country. So I'm excited. Kidney care in general is leading all of health care in the shift from volume to value-based care and reducing care fragmentation by compensating providers for really improved clinical access, clinical outcomes, quality of life, patient related outcomes rather than just the number of services that are rendered or the number of treatments that are given. Dr. Giullian: 12:44 Kidney care providers continue to prove that the drive towards integrated care inspires innovation and the delivery of better outcomes compared to what's called the traditional fee-for-service models. So for health systems, for payers, for providers, this means moving to the value-based reimbursement models and managing risk. And it's really about managing what we call outlier populations. Patients that don't necessarily fit in the "norm" from a clinical standpoint. And those can be small in number, but they tend to be very high in acuity, and they tend to be high in cost. And patients with kidney disease often fall into these categories. Dr. Giullian: 13:27 And so what we're focused on, and what the entire community is focused on right now, is managing the total cost of care for these patients. And I would say this is where DaVita and our partner nephrologists are really in the best position to manage the total cost of care for patients and improve their clinical outcomes. And this is true for patients with advanced stage chronic kidney disease. It's also true for those patients with end stage kidney disease. I think value-based care enables the delivery of holistic care across the entire continuum. And this results in patients staying healthy longer and avoiding hospitalizations. And for me as a clinician first, first and foremost, this is really what we want to achieve on behalf of our patients. Halie Peddle: 14:08 Dr. G., thanks for joining us again today and sharing more on your clinical vision for DaVita. Dr. Giullian: 14:13 Thank you for having me. I appreciate it. Halie Peddle: 14:15 Listeners, thank you for tuning in and be sure to check out other DaVita Medical Insights episodes for more kidney care educati…

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The Importance of Predictive Analytics Feb 26, 2020

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Successful use of predictive analytics gives us the ability to minimize unwanted future events and maximize future health without unnecessary expenditure of resources, according to Vice President and Medical Director of DaVita Health Economics and Outcomes Research, Steven Brunelli, MD. Listen to this podcast, in which Ryan Weir interviews Dr. Brunelli on predictive analytics. Dr. Brunelli discusses why predictive analytics are so important; what makes patients with kidney disease well-suited to predictive analytics; how to take a dataset and make it beneficial for patients, physicians and health plans; how an ideal CKD model is defined; how predictive analytics support value-based care arrangements; and finally, how predictive analytics might be used in health care in the future. Listen and read more DaVita Medical Insights here. Podcast Transcript: Ryan Weir: 00:34 Hello everyone, and welcome to the DaVita Medical Insights Podcast. I'm your host Ryan Weir, and I'm part of DaVita's communications team. Today, we'll dig into predictive analytics with Dr. Steve Brunelli, Vice President for DaVita Clinical Research. Dr. Brunelli, thank you so much for joining us today. Dr. Steve Brunelli: 00:49 Thanks for having me. It's a pleasure to be here and I'm excited to talk about predictive analytics, which is something that I think is going to be transformative in health care and in kidney care, in particular. Ryan Weir: 01:00 That's great. Let's dive right in. In health care, everyone is talking about predictive analytics. Could you tell me why predictive analytics are so important and why now? Dr. Steve Brunelli: 01:11 All right, I'll take that question in two parts. So the first part is: why predictive analytics? The answer is that predictive analytics let us get the right treatment to the right patient at the right time, and that's critically important. As our armamentarium of therapies grow, it's important to be able to target those therapies in efficient ways and in ways that will maximize the benefit to patients. Predictive analytics give us an increasing sophistication in how we deliver those services to patients. Dr. Steve Brunelli: 01:48 To understand why now, I think it helps to kind of get a historic perspective. So predictive analytics did not spring full form from the head of Zeus. They didn't fall from the sky or come down on stone tablets. They're really an extension and an acceleration in the sophistication of a paradigm that we've used for many years. I liken it to the origins of rock and roll in the 1950s or hip hop in the 1980s. Those didn't derive de novo. They were extensions of prior musical traditions that suddenly accelerated and became exciting and new. That's what we're seeing in predictive analytics. Dr. Steve Brunelli: 02:29 So what are the permissive conditions that allow for that? The first is we have, by historic standards, an unprecedented amount of data at our fingertips. As electronic health records have increased in their size and their scope, doctors used to scribble notes on index cards and stick them in a drawer in their office, and now everything is on databases in codified fields where people can easily find and index them. Those systems are becoming increasingly interconnected. We have the ability to connect not only various points in health care, doctor's notes, but also labs, observations of the payers like claims. So we have at our disposal now a level of information that didn't exist in prior eras. Dr. Steve Brunelli: 03:24 At the same time, there's been an explosion of computing power. So the iPhone 5, I'll add, it's in my pocket, is actually a more powerful computer than all the computers that landed the first module on the moon. So when you think about what that allows, and predictive analytics are really an extension of pattern recognition. So doctors have been looking for patterns of symptoms and signs and using that to govern therapies for as long as they've been treating patients. When you take that paradigm and you add that amount of data and computing power at that magnitude, you're able to appreciate patterns in those data and signs in those data that you could never pick up with the human mind. I mean the human mind can only hold about seven pieces of information in active memory and the computer can consider thousands of thousands of those. It can look at combinations of those and the timing of those and identify those patterns in ways that are very powerful and allow us to be much more accurate and precise in the predictions that we make. Ryan Weir: 04:40 That's great. So what makes patients with kidney disease unique and well-suited to predictive analytics? Dr. Steve Brunelli: 04:47 So kidney disease, I think, is probably the most fertile field for the development of predictive analytics, and there are a few pieces that go into that. So comparatively, first and foremost, if you want to be able to identify all the patterns, you need data on lots and lots of patients. For better or worse, better in the case of predictive analytics, but worse in the case of overall health of the population, kidney disease is very common. There are tens of millions of people in the U.S. with kidney disease, known and unknown, and that makes it easy to study. Dr. Steve Brunelli: 05:17 The second piece is that kidney disease and the outcomes that we think about with our predictive analytics, by and large, are relatively objective. So if I want to know if someone has kidney disease, I just need to look at a couple of their labs. Conversely, if I want to know if someone has lupus, there's a whole battery of signs and symptoms and there's various combinations, you assign points. If the patient complains of arthralgia in different points, if they have a rash that's in one part of the face versus the other part of the face. So it's a lot easier when you're training the models in that first step, when you're teaching the models to look for the patterns, when the outcomes that you're interested in are something that are easily definable in the data and are easy to find in the data. So it's easy to find an eGFR lab result. It's easy to find a hospitalization event. It's much harder to find a physician's observation from a physical exam that could be recorded in myriad ways and myriad places in an EHR. Ryan Weir: 06:28 So it sounds like the data points with patients with kidney disease are a little bit more clear cut. Dr. Steve Brunelli: 06:32 That's absolutely true. I think the third piece is that, unfortunately, we know that other health events, important health events like hospitalization, like death are common in patients with kidney disease. And again, things being common make it easier to train predictive models to identify the patterns that can then pre-stage those. Ryan Weir: 06:56 So how do you take that data and make it beneficial for patients, physicians and health insurance plans? Dr. Steve Brunelli: 07:03 So to build a model, you need several key ingredients. So the first is you need, as we talked about, a large set of data on a large number of patients, and those patients need to be broadly representative of the patients who you intend to use the modeling. You also need the right technologies and the right tech technical expertise to run those technologies. Then the last key piece, and I can't understate this piece enough, is that you need the right clinical expertise to filter down, to oversee all of that, and to make sure that the patterns that you're teaching the algorithm to look for make sense clinically. You don't build in paradoxes, you don't include fluke associations in your predictive models. Dr. Steve Brunelli: 07:52 So when you take those elements and you put them together, what you do in a large set of data is first you define the population that you want to build the model in. You identify the patients who developed the event that you're trying to predict. So we'll take the case of our hospitalization model. We identify the patients who went on to be hospitalized in some prescribed period of time and, at the same time and by the flip side of the same token, we identify the patients who didn't get hospitalized during that period. So we have our target patients and our controls. Then you step back in time to a period before, the period where you would be making that prediction and you say, "Based on the data, what are all of the things that I could have known about the patient at that moment in time?" Dr. Steve Brunelli: 08:42 Then through a series of complicated and intricate steps, you teach the computer different ways of looking for patterns between those upstream elements and the event/non-event status of the patient. Typically, so when we built the hospitalization model, we didn't build one model, we built about 65 models. Each one of those went through a series of refinements, an iterative learning by the machine, until it was as good as it can get. Then we had a horse race and we put the 65 models next to each other and we said, "Which of these 65 is the best?" By the best, I mean the most accurate but also the most reproducible. Dr. Steve Brunelli: 09:25 So when you take a predictive model, it's relatively easy to have it perform well in a development environment, in the population of patients in whom it was developed. The much harder challenge is to take a model that will perform as well in that population as it does into a totally new population. So when we test those models, we test them not only how well do they perform in the development environment, but we export the model to other populations and we look for how well that model can perform externally. Dr. Steve Brunelli: 10:01 So then you have a model and the question is, well, how does that benefit patients? The first thing, as I mentioned, it's important to be able to identify what patient needs a particular therapy right now. In the hospitalization model, there are a whole suite of services that we can provide to patients: telephonic contact, nurse practitioner interventions, dietary interventions, changes to the dialysis prescription, if we know that that patient is at an increased risk of being hospitalized. So we want to make sure that we're providing treatments that will be effective and help people and we want to minimize the instances where someone gets a therapy that might not do them good in the long-term because the risk-benefit isn't there. Dr. Steve Brunelli: 10:53 So predictive analytics, by stratifying people into different tiers, how likely are you to have a hospitalization in the next 90 days? Maybe you're high risk and you need an intensive level of services, you need everything we can do. Maybe you're a moderate risk, you need a stepped up level of services. Or maybe you're just in a population average risk and what you need is just solid, every day care, but you don't need those extra services, different changes to your diet, changes to your dialysis prescription. So it helps us streamline that. Dr. Steve Brunelli: 11:26 From a payer standpoint, be that an insurer, be it a government program, if you're an insurer, you want to know several things. One, you want to know that the resources that you're allocating are being used to maximize benefit in the population it's responsible for. Number two, you don't want to outlay resources that are going to have no benefit downstream. Number three, you want the combination of number one and number two, to prevent future events that will drive up your outlay of costs. So if I can prevent one hospitalization now, I'm going to save as Medicare tens of thousands of dollars two months from now. So I'm very happy to trade off a small investment now to prevent that large expenditure in the future. So from a payer standpoint, these make the delivery of health care and the use of their resources more efficient. Dr. Steve Brunelli: 12:30 Then I left the providers for last. The providers, be it the doctors, nurse practitioners, physician assistants, nurses, everyone, they live in a world sandwiched between the patients and the health care providers, and the health care insurers, I should say. Predictive analytics provide a way of getting everyone pulling in the same direction. And so it simplifies their job in terms of needing to escalate the level of care in certain patients and needing not to escalate the level of care in other patients. Ryan Weir: 13:03 So you mentioned that you looked at about 60 plus different models and you went with the best one. Dr. Steve Brunelli: 13:08 Yeah. Ryan Weir: 13:08 So what does an ideal CKD model look like? Dr. Steve Brunelli: 13:13 So an ideal model, so I would say the most important piece for a model, is that it'd be accurate and reproducible. That I can take it in a population of patients, let's say Medicare Advantage patients who, by and large, will be in their late 60s or 70s, and it will work as well on them as it does in an insurer-based health care group of patients who may be in their 40s and their 50s. It'll work as well in a hyper-urban environment as it will in a rural environment and in a suburban environment. So that's the most important piece. Dr. Steve Brunelli: 13:54 The second most important piece is that a model we built to a very detailed use case. So there are a number of elements that go into that. You need to know what is the outcome that I would like to see from the model? What is the timeline over which I care about that outcome most? I care about it over all times, but there's some timeline that I might care most and I'll give you an example there. Dr. Steve Brunelli:14:24 We built a model that looks at the progression of CKD to end stage renal disease. Now, if someone's going to progress, it's important to know that. But as a doctor, as a clinician, if that patient is progressing and they're going to get to ESRD in 10 years, that implies one set of things that I want to do for that patient. I want to take all steps to mitigate the progression of that disease to the best of my ability. But if that patient is going to accelerate over the next 10 months, there's a whole added suite of things that I need to do. That patient needs to be counseled about transplant; they need to be educated about dialysis modalities; they need dietary counseling. There are a whole host of things that I need to do. So specifying the time horizon over which I care about the outcome becomes critically important. Dr. Steve Brunelli: 15:16 The third piece, and this often gets lost on first blush, but is also critically important, is that when you build a model, you need to understand what the data environment will look like when you go to use the model. So models function like car engines. If you look at the blueprint of a car, there's a series of parts that are connected in a certain way. If you have all the parts, the car runs well, but if you're missing some of the parts, the car won't run. If you're missing a carburetor or, I guess, these days a fuel injector, the car's just not going to run. So it may be the case that if I'm able to feed into a model, build a model that expects lab data, EHR data, and data on social determinants of health, and claims data, I can get to a maximally accurate prediction. Dr. Steve Brunelli: 16:07 But if in my use case I'm not going to have data on social determinants of health and I'm not going to have claims data available to me in real-time, then that super accurate model can't actually work when I need it to work, when I go out to a use case. So when we build…

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