Fragmentation of care as a barrier to optimal ESKD management

Abstract

Caring for patients with end-stage kidney disease (ESKD) in the United States is challenging not only because the epidemiology of the disease's progression is complex, but also because treatment delivery occurs within social and environmental contexts that can be difficult to navigate. Chronic kidney disease (CKD) often results from other conditions, such as hypertension and diabetes. In turn, CKD can contribute to a cascade of new chronic conditions, such as anemia and cardiovascular disease. Notably, 83% of US Medicare fee-for-service program enrollees with CKD have three or more comorbid chronic conditions. 1 As CKD progresses toward ESKD, the number of comorbidities increases, care becomes much more complex and the potential for adverse outcomes increases. 2,3 As a result, care for individuals with ESKD typically involves multiple healthcare providers from multiple subspecialties. In the context of a US healthcare delivery system that has been historically siloed by provider specialty, organization, payment system, and administration,

Facility-Level Variation in Dialysis Use and Mortality Among Older Veterans With Incident Kidney Failure

“…Coordinated policy efforts may be needed to ensure that patient preferences are not overruled by clinical momentum and that dialysis treatment is not provided by default to patients who prefer supportive care but have difficulty accessing these programs. Differences in the availability and organization of supportive care services across facilities may exist that we were not able to ascertain . For example, nutritional counseling to delay the appearance of uremic symptoms as well as coordinated palliative care and social services have been described as important components of kidney supportive care programs in other health care systems …”

“…Differences in the availability and organization of supportive care services across facilities may exist that we were not able to ascertain. 25 For example, nutritional counseling to delay the appearance of uremic symptoms as well as coordinated palliative care and social services have been described as important components of kidney supportive care programs in other health care systems. 26 The absence of statistically significant variation in total mortality rates among older adults with kidney failure served by the VA system contrasts with other work such as the Dialysis Outcomes and Practice Patterns Study, which has found marked variation in mortality after dialysis initiation, leading many to speculate that dialysis selection and initiation practices may underlie this variation.…”

Shared decision-making and planning end-of-life care for patients with end-stage kidney disease: a protocol for developing and testing a complex intervention

“…One of the challenges for this research is the lack of prior empirical evidence to inform the structure and content of a complex SDM intervention for EoLC planning and decision-making in patients with ESKD. To the best of our knowledge, this is the first study to develop an intervention for patients with ESKD designed to facilitate EoLC planning and decision-making as part of a SDM process within Denmark and internationally [ 55 , 56 ]. The findings from the scoping review, the interview studies, and user-centered design workshops with patients, relatives, HPs and experts in patient involvement interventions for kidney disease are essential to ensuring a sustainable intervention is developed for evaluation in kidney services.…”

The Role of Dialysis Organizations in Promoting and Facilitating Access to Nondialytic Treatment Options

“…However, care pathways for different treatment modalities have been historically siloed, and the resulting fragmented care is inefficient at best and harmful for patients at worst. 10 A model of integrated care necessitates communication and collaboration between dialysis centers, nephrologists, transplant centers, hospice agencies, and other care providers. Formal and informal networks of care providers are emerging, including interorganizational relationships intended to address the diverse needs of people with kidney disease throughout their lives.…”