W' Charles ONeill

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INTRODUCTION

• W. Charles ONeill
• EmoryUniversity

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HISTORY OF DIAGNOSTIC AND INTERVENTIONAL
NEPHROLOGY U.S.

• 1998 first PGE course on nephrology procedures
• 1999 at second course, faculty proposes a
  society
• 2000 American Society of Diagnostic and
  Interventional Nephrology founded
• 2003 certification in procedures begun
• 2005 first ASDIN clinical and scientific meeting
  
• 2008 12th annual PGE course at ASN

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American Society of Diagnostic and Interventional
Nephrology
Expanding the future of nephrology to provide
complete care to our patients by promoting the
procedural aspects of nephrology

• Sonography and biopsy
• Hemodialysis catheters
• Arteriovenous grafts and fistulae
• Peritoneal dialysis catheters

www.ASDIN.org
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American Society of Diagnostic and Interventional
Nephrology
Expanding the future of nephrology to provide
complete care to our patients by promoting the
procedural aspects of nephrology

• Standards of care
• Certification and accreditation
• Scientific meetings and publications
• Training

www.ASDIN.org
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Procedures performed in US training
programsBerns and ONeill, CJASN 2008
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PROGRAM

• PD catheters Michael Kraus (Indiana Univ.)
• Ultrasonography Charles ONeill (Emory)
• IN hospital-based Joseph Bonventre (Brigham)
• IN joint with radiology Ivan Maya (UAB)
• IN free-standing unit Jack Work (Emory)
• Training faculty Arif Asif (Univ. of Miami)
• Certification and accreditation Charles ONeill
• Questions and answers all speakers

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PD Catheter Insertion ProgramASN Fellowship
program

• Michael A Kraus, MD
• Indiana University/ Clarian Health
• November 5, 2008

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Requirements for Training

• Faculty ASDIN prefers 2
• 1 good one is essential
• Facilities
• Can be placed bedside
• Nephrology Procedure suite preferred
• Ease in scheduling, control, oversight
• GI suite used
• OR
• Anesthesia good and bad
• Trained nurses
• Equipment more toys, more loss

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Requirements for Training

• VOLUME
• Patients are essential
• 25 of programs without PD
• Need to keep skills for faculty
• 10 per year minimum
• Need to keep volume for fellows
• Education see one
• Experience do a couple
• Competency at least 10, more better

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Did I say volume?

• How many of us would chose in-center dialysis if
  transplant was not available
• US 94 on in-center HD
• lt6 - PD
• 3,000 patients on home short daily dialysis
• Academic centers are not taking the lead

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Requirements for training

• QAPI
• Catheter survival with and without intervention
• PD technique survival
• Peritonitis rate
• Exit site infection rate
• Kt/V

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Indiana University program

• About 50 PD patients
• Average 2.1 new patients per month
• 25 40 catheters per year
• Catheters placed by nephrology gt95 of the time
  transplant surgery now referring them.
• Peritonitis rate 1/24
• Technique survival 50 at 30 months

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Censored Technique Survival
Censored for transplant, death, and renal recovery
SDHD 75 40 22 9 CAPD
105 69 40 20 11
4 3
Data on file, Indiana University Medical
Center/Clarian Health Partners
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IU Program

• All placed with peritoneoscopy utilizing the
  Y-tec equipment/technique
• All placed in OR with anesthesia providing
  monitored anesthesia
• All are placed when needed no buried catheters

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Peritoneoscopy
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Fellowship

• Training in PD mandatory for all
• Multiple didactics
• Theory, physiology, Clearance
• How-to
• Infectious complications
• Non-infectious complications
• Inpatient orders small all 5-prong
• Outpatient experience
• 2nd year fellows have 6 months of clinic (PD or
  PD and home HD). May have as much as they desire.

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Fellowship training in PD catheters

• Mandatory - On hour lecture on techniques and
  complications given yearly to all fellows
• Beginning of year to benefit 2nd years
• Chapter on PD catheter placement
• Dialysis Access - a multidisciplinary approach.
  Editors Gray and Sands. 2002 Chapter 38 -
  Techniques of PD catheter insertion
• Y-tec CD www.medigroupinc.com

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Fellowship training in PD catheters

• Elective ranges from curious to competent
• 2nd and 3rd year fellows are invited to watch and
  learn.
• Fellow participation is quite variable
• Watch first scrubbed in
• Hands on second as capable
• Certified only if deemed competent with at least
  10 catheters must keep track of procedures.

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Success?

• 5 8 fellows over last 15 years perform PD
  catheter placements in their practices
• With move to OR and recent years, less fellows
  are participating in elective program
• Reasons No desire, too busy with research
• 730 OR start time for most cases
• 1 outside nephrologist trained with us outside of
  fellowship.

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Conclusion

• Training on PD catheter placement is possible
  during a nephrology or IN fellowship - all
  fellows need exposure.
• Outcomes better for patients with involvement in
  placement and program.
• Needs a PD program
• Can be done in any procedure suite
• Technically easy procedure with good outcomes.

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ESTABLISHING ANULTRASONOGRAPHY PROGRAM

• W. Charles ONeill
• EmoryUniversity

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Why should nephrologists be sonographers ?

• Patient convenience
• Clinical correlation usually required
• Better interpretation
• Saves physician time
• Not a difficult skill to learn

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THE FEARS

• They wont let us do it.
• It will lose money.
• Lack of skilled faculty.
• No room in the fellows schedule.

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HISTORY OF RENAL ULTRASONOGRAPHY AT EMORY
mid 1992
First study using echocardiography scanner
1993
Studies performed on nonbilling basis with no
reports Bedside biopsy marking
January 1994
Renal Division purchases machine Formal billing
with reports in Progress Notes Formal rotation
for fellows
May 1996
Formal approval by Medical Director of hospital
July 1996
Report form approved Reports placed in Radiology
section of patient chart Database started
June 1997
Contract with hospital to recover technical costs
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Overcoming obstacles

• Turf issues
• There is no rule that only radiologists can do
  ultrasound
• There is no rule that nephrologists cant do
  ultrasound
• Get certified
• Winning battles
• Emphasize advantages for patients
• Emphasize potential cost savings for hospital
  ICU studies, not occupying radiology suite during
  biopsies, bladder studies, etc.

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THE FEARS

• They wont let us do it.
• It will lose money.
• Lack of skilled faculty.
• No room in the fellows schedule.

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YEARLY COSTS AND REVENUES
Gross
Net
Equipment (30,000) over 5 years
(6,000)
Two outpatient studies per week
Four inpatient studies per week
7,400
1,400
2 outpatient, 3 inpatient per week
16,550
10,550
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1994
1995
1996
1997
1998
1999
2000
2001
2002
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THE FEARS

• They wont let us do it.
• It will lose money.
• Lack of skilled faculty.
• No room in the fellows schedule.

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FACULTY

• Initially should be single faculty member
• Must be adequately trained (with documentation)
• Will require up to 20-25 effort (once program
  established)
• Must be available to assist with studies
• Train and supervise additional faculty

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RESOURCES FOR FACULTY

• Training courses
• Ultrasonography For Nephrologists
• Minifellowship in Renal Ultrasonography
• Training materials
• Atlas of Renal Ultrasonography
• Renal Ultrasound Teaching CDs
• Website www.medicine.emory.edu/RENAL/ultrasound
• Certification www.ASDIN.org

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THE FEARS

• They wont let us do it.
• It will lose money.
• Lack of skilled faculty.
• No room in the fellows schedule.

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FELLOWS

• Fellows want to be trained in ultrasound
• Very educational experience
• Training time depends on volume about 20-30
  studies
• Minimal supervision required after about 60
  studies

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Interventional Nephrology Hospital Based
Nephrology Program
Incorporating Diagnostic and Interventional
Nephrology into Training Programs, Renal
Week ASN, 2008
Joseph V. Bonventre MD PhD Director, Renal
Division Brigham and Womens Hospital Harvard
Medical School
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Why Incorporate Interventional Nephrology?

• Better patient care with early intervention,
  better outcomes Nephrologist/interventionalist
  is more likely to screen and better able to make
  informed decisions regarding access with a better
  understanding of the patients history and
  implications of access decisions.
• Ultrasonography is becoming an Internists tool
  and should be central to a Nephrologists
  toolkit. Also helps greatly with biopsies and
  facilitates care and research in transplant
  patients by facilitating protocol biopsies.
• More awareness of access issues among non-IN
  attendings and trainees.
• Encourage research in vascular access.
• Has become an important aspect of Nephrology
  which will benefit as a discipline by having more
  procedures.

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Hurdles to Overcome to Establish a Program in
Interventional Nephrology?

• Perceived ownership of these procedures by
  Radiology, Interventional Radiology and Surgery.
• Recruitment of trained Interventional
  Nephrologists/vs training ones own.
• Access to facilities with true freedom to
  operate (?inside or outside hospital).
• Staffing need for nursing dedicated to the task.
• Finances Professional collections much much less
  than hospital collections- How does one get more
  support from hospital?
• Conflict of interest concerns in outside dialysis
  units.

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Recipe for Growing your own Interventional
Nephrologist

• Take a junior faculty member who is interested in
  an academic career, who is interested in
  procedures, is meticulous in technique (helps to
  work with zebrafish), interested in a challenge,
  tactful in dealing with other sub-specialties and
  staff, persistent, someone who at one time
  thought about surgery as a career, who wants to
  make IN their niche in the academic center.
• Obtain financial resources for training (we used
  an internal granting program and divisional
  funds)
• Find one of your colleagues who will be willing
  to provide intensive training
• Encourage visibility of individual to dialysis
  patients and nurses
• Support through interminable issues with
  facilities, staffing, hospital administrators
• Encourage a trainee to go into IN to partner with
  the pioneer.

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Starting your own Interventional Nephrology
Program

• Seek advice from as many sages in the field as
  possible.
• Try to recruit one of these sages but you will
  probably be unsuccessful (Too expensive, too
  settled etc.).
• Talk at length with Radiology focusing on
  cooperation but independence.
• Try a Trojan Horse approach if you can think of
  one.
• Fight for as many resources from the hospital as
  you can, focusing on the advantages to the
  patient and the financial benefit to the
  hospital. Be persistent!

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Month
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Conclusions

• Interventional Nephrology has become a central
  part of Nephrology.
• Patient care and patient experience is improved
  by having a IN program.
• Many trainees are interested in getting increased
  exposure to IN.
• Academic IN programs in hospitals have many
  turf and financial challenges.
• Despite the challenges kidney patients and
  Nephrology as a discipline must embrace IN and
  make it central to our faculty activities and
  training programs.

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Interventional nephrology joint program with
radiology

• Ivan D. Maya, MD, FACP
• Associate Professor of Medicine and radiology
• Director of Interventional Nephrology
• University of Alabama at Birmingham
• November 5, 2008

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Patients on dialysis at UAB

• UAB provides medical care for approximately 500
  hemodialysis and 90 peritoneal dialysis patients.
  
• Two full-time access schedule all access
  procedures, and maintain a prospective,
  computerized database of all vascular access
  procedures .

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Before July 2004

• At the UAB, interventional radiologists were
  taking care of 100 of the dialysis endovascular
  access procedures until July 2004.

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Joint program Nephrology and Radiology

• The departments of medicine and radiology at UAB
  decided in 2004 to create a combined
  interventional nephrology program.
• The agreement gave 40 interventional time to
  nephrology and 60 to radiology.
• Professional charges are divided 40/60.
• Technical charges go to hospital.

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Joint program Nephrology and Radiology

• Nephrology has dedicated room in IR.
• Scheduling is done by nephrology (2 vascular
  access coordinators).
• Nephrology and radiology cross-cover each other.
• Renal fellows also trained by IR faculty.
• IR fellows also trained by nephrology faculty

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Procedures performed from October 1 / 2007 to
September 30/2008

• Angiography 441
• Angioplasty 340
• Thrombectomy 180
• Tunnel catheter placements 275
• Tunnel catheter exchange 220
• Non-tunnel catheter placement 41
• Venograms 22
• Stent deployment 62
• Obliteration of accessory 10
• Peritoneal catheter placement 7
• Kidney biopsies 124

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New Procedures added to the IR after 2004

• Femoral tunneled HD catheters.
• Trans-hepatic tunneled catheters.
• Peritoneal Catheter placement.
• Peritoneal catheter maintenance.
• Real-time ultrasound guided renal biopsy.
• Post renal biopsy color Doppler surveillance US.

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Research and Publications

• Grants Young Investigator Award NKF 2006-2008
  NIH K-23 2008-2013.
• 10 abstracts
• 8 research papers
• 1 book chapter

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Training

• Since 2005, we have trained 4 nephrology fellows,
  one at the present time.
• In 2008, offering a third-year fellowship.
• The trainee will be exposed to a combined
  interventional, teaching and research fellowship.
  
• Our mission is to train fellows for an academic
  career.

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ASDIN Symposium onInterventional NephrologyOne
Size Does Not Fit All

• Hospital-based nephrology service
• Joint program with radiology
• Free-standing vascular access center

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Why have an free-standing Access Center?A Case
Presentation
50 year old with diabetes, ESRD presents for his
usual dialysis Wednesday at 11am where his graft
is found to be thrombosed.
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Chain of Command How It Used to Be
Hospital 1
Hospital 2
Dialysis Unit Patient
Nephrologist
Surgeon
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Patients Perspective
Hospital
Access Center

• Wait for RN to make calls to surgeon,
  nephrologist and/or radiology
• Go to hospital
• Wait at hospital
• Procedure
• Too late to get dialysis
• Hypoglycemia because npo all day
• Spend night in hospital
• Dialysis in morning
• Discharge

• One call to access center
• Go to center
• Procedure
• Return for outpt HD same day
• Sleep in his own bed that night

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Nephrologists Headache Factor
Access Center
Hospital

• Call from dialysis unit
• Call on arrival to hospital
• Call from nurse for BP 182/95
• Call after procedure because blood sugar is 50
  mg/dl
• Manage sugars and arrange for observation
  overnight
• See patient on dialysis in AM
• Discharge

• No call from dialysis unit
• No call from hospital
• Faxed report of procedure same day
• Call from interventional physician but only rarely

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Providers Prospective

• Decrease stress on staff by
• Providing one call shopping
• Access problem solving
• Marked time saving in dealing with access related
  problems
• Marked decrease in missed treatments

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Why Have An Access Center

• Patients
• Quicker service
• Payors
• Outpatient procedures less expensive
• Surgeons
• No calls for thrombosed access
• Hospital work becomes elective
• Nephrologists
• Major problem for ESRD patients
• More efficient patient care
• Quality / ? Pay for performance

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Free-standing Access Center
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Free standing Access Center
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Free standing Access Center
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Free standing Access Center
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Atlanta ExperienceDialysis Access Center of
Atlanta

• Extension of Emory Clinic opened January 2003.
• Performed over 8000 procedures
• Patient base of 500 which represents about 50 of
  referrals.
• Barriers
• Surgery
• Expanded referral base 30
• IR
• Provide same/next day service

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Which size fits best?
Economic Model Reward Risk Note Hospital
(Hungry) Low Low Prof fee
only ASC Low Low Prof fee only
Ownership Moderate Moderate
global Extension of High High
global Practice (managed) Moderate High
global
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Free-standing Access CenterTo be managed or
not, that is the question!

• Hospitals able to pass supply costs through,
  free-standing facilities are not- comes off the
  bottom line!
• Free-standing financial success depends on case
  volume and case mix, as well as controlling
  procedural supply costs.
• The larger the patient base the better.
• Management services are expensive 10-25 of
  profit.
• After all costs are paid, the management service
  takes it share first!
• Beware the Pro forma!
• Read the management service contract carefully,
  all the risk is placed on the practice.
• Joint ventures are now available to lessen the
  relative risk.
• Multiple practices forming a LLC? Has not been
  tested legally.

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Free-standing Access Centerthe good, the bad,
and the ugly

• The Good
• Trained 9 academic, and 20 private practice
  Interventional Nephrologists
• Changed vascular access care in Atlanta
• Generated over 4,500,000 for Renal Division
• The Bad
• Not all faculty on board.
• Not successful in integrating vascular access
  education into the fellowship program.
• The Ugly
• There are now 7 vascular access centers in
  Atlanta.
• Patient volume declining.

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Free-standing Access Centerthe bottom line!

• Safe, effective and efficient patient care
  offering the most cost savings to the health care
  system.
• Do not compete for resources.
• Higher reward in terms of revenue stream but at a
  higher risk.
• Likely will be transformed into an ASC setting by
  2012.

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Some thoughts on the future designed to stir the
pot of discussion

• The current private (management services)
  practice model of training is unsustainable and
  will eventually fail.
• Has driven change and built momentum and demand,
  but
• Current trainees will retire and no system in
  place to train for future needs
• Limited trainers growth has outstripped capacity
  to effectively train new interventional
  nephrologists
• As centers develop within smaller practices,
  volume and variety of patient base for training
  becomes a limiting factor
• Training needs to evolve to a minimum number of
  training months- 3 months is barely adequate
• Academic programs to evolve to a third year
  fellowship similar to transplant nephrology
• Training centers need minimum patient volume in
  order to provide adequate experience

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Some thoughts on the future designed to stir the
pot of discussion

• ASDIN curriculum based on GBs manual will become
  the basis of training programs.
• Academic training will continue to grow slowly
  unless trainee demand drives program
  development.
• Funding of Training programs remains an issue.
• Industry will begin to help support academic
  training by sponsoring fellowships.
• Residency Review Committed Approved Subspecialty
• ACGME certification of academic training programs
  and the ABIM certification of trainees- is this
  a desirable route to pursue?

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The End
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Faculty Training

• Arif Asif, M.D.
• Director, Interventional Nephrology
• Associate Professor of Medicine
• University of Miami Miller School of Medicine
• Miami, FL

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Faculty Training

• Renal ultrasonography
• Peritoneal dialysis catheter-related procedures
• Hemodialysis access-related procedures

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Faculty Training

• Renal ultrasonography
• Ultrasonography course
• Ultrasonography mini-fellowship

Emory University, Atlanta Georgia
Duration 2 days 5 days Total tuition cost
1250
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Faculty Training

• Peritoneal dialysis catheter-related procedures
• University of Miami
• Louisiana State University
• Arizona Kidney Disease and Hypertension
  Center
• University of Indiana

Duration 8 catheter insertions, based
availability Total tuition cost approx. 8000
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Faculty Training

• Hemodialysis access-related procedures
• Academic centers
• Private practice

Duration 3 6 months Total tuition cost
30,000 - 50,000
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Faculty Training

• Where do we go from here?

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American Society of Diagnostic and Interventional
Nephrology
www.asdin.org

• Certification
• Accreditation

www.ASDIN.org
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American Society of Diagnostic and Interventional
Nephrology
www.asdin.org

• Certification (individual physicians)
• Accreditation

www.ASDIN.org
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American Society of Diagnostic and Interventional
Nephrology
www.asdin.org

• Certification (individual physicians)
• Accreditation (training programs)

www.ASDIN.org
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American Society of Diagnostic and Interventional
Nephrology
www.asdin.org

• Certification
• Accreditation

www.ASDIN.org
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Sonography

• Required training
• 6 weeks during fellowship or
• 50 CME-accredited hours
• Required experience
• 125 performed and/or interpreted
• At least 80 supervised
• Remainder with confirmation (documented in up to
  20)
• Submitted studies
• Normal
  Nephrolithiasis
• CRF Biopsy
  marking
• Cyst Allograft
• Hydronephrosis

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Peritoneal catheters

• Required training
• 2 hr practice on models, anesthetized animals, or
  human cadavers with the successful insertion of
  at least 2 catheters
• Observation of the placement of 2 catheters in
  patients
• Required experience
• Placement of 6 catheters with documented outcomes
• Documentation by a physician certified in
  catheter placement

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Interventional Procedures

• Required training
• Principles of dialysis
• Anatomy and examination of vascular access
• Fluoroscopy and radiation safety
• Conscious sedation
• Equipment and catheter design
• Required experience (as primary operator)
• Angiography, angioplasty, and declotting 25 of
  each
• Short-term catheters 25 cases
• Cuffed, tunneled catheters 10 cases
• Submitted studies
• Angiography 10 cases for AVG, 10 cases for AVF
• Angioplasty 10 cases for AVG, 10 cases for AVF
• Declotting 10 cases for AVG, 2 cases for AVF
• Tunneled catheters 10 cases

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American Society of Diagnostic and Interventional
Nephrology
www.asdin.org

• Certification
• Accreditation

www.ASDIN.org
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Sonography

• Faculty
• At least one ASDIN-certified faculty
• Other faculty must be ASDIN-certifiable
• At least 0.25 FTE devoted solely to sonography
• Facility
• Adequate equipment and supplies
• Adequate record-keeping
• Procedural volume
• 300 per year
• Didactic training
• Lectures, books, articles
• Evaluation

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Peritoneal catheters

• Faculty
• At least two ASDIN-certified or certifiable
  faculty
• Facility
• Appropriate procedure room
• Adequate equipment and supplies
• Adequate record-keeping
• Procedural volume
• 50 cases prior to the application date
• Didactic training
• Lectures, books, articles
• Evaluation

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Hemodialysis Access

• Faculty
• At least one ASDIN-certified faculty
• At least one FTE interventional nephrologist per
  unit
• Facility
• Appropriate space, layout, and funding
• Adequate equipment and supplies
• Adequate staffing (nurse, tech)
• Adequate record-keeping
• Procedural volume
• Angiography 300 per year
• Angioplasty 300 per year
• Thrombectomy 100 per year
• Tunneled catheters per year
• Didactic training
• Lectures, books, articles
• Evaluation