Exploring attitudinal barriers to participation in inpatient fall risk assessment using the Theoretical Domains Framework: A survey of providers.

Background and Aims: Lack of provider (physicians and advanced practice providers) participation in fall risk assessment was theorized to be contributing to rising rates of falls with injury at our institution. This project sought to identify if attitudinal barriers to inpatient provider participation in fall risk assessment were similar to those identified in other clinical settings. Methods: Barriers to provider participation in fall risk assessment were identified in the literature. These were mapped to the Theoretical Domains Framework (TDF) domains to assist with interpretation of the data. A 10-item survey using a 5-point Likert scale (strongly agree to strongly disagree) with two open-ended questions was developed using these barriers. The survey was distributed via email to all providers on the Medical Staff in July 2021. Results: The response rate was 9.1% (188/2062). 72.6% (95% confidence interval [CI]: 65.6, 78.5) of providers at our institution did agree that fall risk assessment was within their role and 72% (95% CI: 66.1, 78.5) agreed that assessment can prevent falls. Nearly half felt that they lacked formal training in fall risk assessment (48.1% [95% CI: 41.1, 55.1]) and 52.2% (95% CI: 44.6, 58.6) agreed that other aspects of patient care took priority over falls assessment. These barriers correlated best with the TDF domains of Beliefs about Capabilities and Beliefs about Consequences. Conclusions: Survey results indicate that interventions focused on increasing provider motivation and capability regarding fall risk assessment and helping providers prioritize fall risk assessment are potential targets for future quality improvement projects.

Kidney Mentoring and Assessment Program for Students: a guide for engaging medical students in nephrology.

BACKGROUND: The American Society of Nephrology's (ASN) Workforce Committee created a unique program called the Kidney Mentoring and Awareness Program for Students to engage medical students in the fight against kidney diseases and interest them in careers in nephrology. METHODS: The program provided a framework and 2 years of funding to three medical schools to organize and carry out health screenings in underserved areas of their communities as well as a structure for student mentoring by the practicing nephrologists. RESULTS: The Workforce Committee identified three medical schools (Emory University, Atlanta, GA; Indiana University, Indianapolis, IN and University of Louisville, Louisville, KY) and engaged faculty at each school to serve as advisors. The ASN committed funding to the groups for 2 years, after which the groups became self-sufficient. Three nephrologists participated in each chapter, building on existing relationships with community groups to identify sites and carry out kidney screening events. CONCLUSIONS: We report here the experience of those chapters and a blueprint for other schools interested in setting up a similarly structured program to interest students in nephrology while working with community groups to spread awareness of the major underlying causes of kidney disease.

Increasing Medical Student Interest in Nephrology.

BACKGROUND: Interest in nephrology careers is declining, possibly due to perceptions of the field and/or training aspects. Understanding practices of medical schools successfully instilling nephrology interest could inform efforts to attract leading candidates to the specialty. METHODS: The American Society of Nephrology Workforce Committee's Best Practices Project was one of several initiatives to increase nephrology career interest. Board-certified nephrologists graduating medical school between 2002 and 2009 were identified in the American Medical Association Masterfile and their medical schools ranked by production. Renal educators from the top 10 producing institutions participated in directed focus groups inquiring about key factors in creating nephrology career interest, including aspects of their renal courses, clinical rotations, research activities, and faculty interactions. Thematic content analysis of the transcripts (with inductive reasoning implementing grounded theory) was performed to identify factors contributing to their programs' success. RESULTS: The 10 schools identified were geographically representative, with similar proportions of graduates choosing internal medicine (mean 26%) as the national graduating class (26% in the 2017 residency Match). Eighteen educators from 9 of these 10 institutions participated. Four major themes were identified contributing to these schools' success: (1) nephrology faculty interaction with medical students; (2) clinical exposure to nephrology and clinical relevance of renal pathophysiology materials; (3) use of novel educational modalities; and (4) exposure, in particular early exposure, to the breadth of nephrology practice. CONCLUSION: Early and consistent exposure to a range of clinical nephrology experiences and nephrology faculty contact with medical students are important to help generate interest in the specialty.

Aligning Strategic Interests in an Academic Medical Center: A Framework for Evaluating GME Expansion Requests.

BACKGROUND: In 2017, the Maine Medical Center Graduate Medical Education Committee received an unprecedented number of requests (n = 18) to start new graduate medical education (GME) programs or expand existing programs. There was no process by which multiple programs could be prioritized to compete for scarce GME resources. OBJECTIVE: We developed a framework to strategically assess and prioritize GME program expansion requests to yield the greatest benefits for patients, learners, and the institution as well as to meet regional and societal priorities. METHODS: A systems engineering methodology called tradespace exploration was applied to a 6-step process to identify relevant categories and metrics. Programs' final scores were peer evaluated, and prioritization recommendations were made. Correlation analysis was used to evaluate the relevance of each category to final scores. Stakeholder feedback was solicited for process refinement. RESULTS: Five categories relevant to GME expansion were identified: institutional priorities, health care system priorities, regional and societal needs, program quality, and financial considerations. All categories, except program quality, correlated well with final scores (R 2 range 0.413-0.662). Three of 18 requested programs were recommended for funding. A stakeholder survey revealed that almost half of respondents (48%, 14 of 29) agreed that the process was unbiased and inclusive. Focus group feedback noted that the process had been rigorous and deliberate, although communication could have been improved. CONCLUSIONS: Applying a systems engineering approach to develop institution-specific metrics for assessing GME expansion requests provided a reproducible framework, allowing consideration of institutional, health care system, and regional societal needs, as well as program quality and funding considerations.

Tailored Rabbit Antithymocyte Globulin Induction Dosing for Kidney Transplantation.

BACKGROUND: Rabbit antithymocyte globulin (rATG) is the most widely used kidney transplant induction immunotherapy in the United States. It was recently Food and Drug Administration approved for this indication with typical dose recommendations of 1.5 mg/kg for up to 7 days given via a central line. METHODS: We theorized that reduced rATG dosing when compared with conventional dosing (6-10.5 mg/kg) is safe and effective, leading to development of a risk-stratified treatment protocol. Five-year data from a retrospective cohort of 224 adult kidney transplants (2008-2013) with follow-up through 2015 is presented. Cumulative rATG doses of 3 mg/kg were administered peripherally to nonsensitized living donor recipients, 4.5 mg/kg to nonsensitized deceased donor recipients. A subset of higher immunologic risk recipients (defined as history of prior transplant, panel reactive antibody greater than 20%, or flow cytometry crossmatch positivity) received 6 mg/kg. RESULTS: There were no differences in patient or graft survival between the 3 groups. One-year rejection rates in the first 2 groups were 8.3% and 8.8%, respectively, comparable to contemporaneous rates reported to the Scientific Registry of Transplant Recipients. Dose tailoring permitted substantial cost savings estimated at US $1 091 502. Mean length of stay fell by almost 3 days as the protocol was refined. There were no episodes of phlebitis. Infection rates were comparable with those reported to the Scientific Registry of Transplant Recipients. CONCLUSIONS: The novel findings of the current study include peripheral administration, reduced dosing, favorable safety, excellent allograft outcomes, and clear associative data regarding reduced costs and length of stay.

Quality measures in acute kidney injury.

PURPOSE OF REVIEW: Quality measure assessment and reporting is evolving in end-stage renal disease care and is inchoate in ambulatory nephrology clinic care. Acute kidney injury (AKI) quality measures have not received sufficient attention, yet deserve consideration in view of the substantial proportion of effort nephrology providers devote to AKI care. RECENT FINDINGS: Accumulating literature permits consideration of timing of nephrology consultation, follow-up after AKI hospitalization, early detection, medication dosing, hospital readmissions and length of stay, cost, and mortality as potential AKI quality measures. SUMMARY: We review candidate AKI quality measures and assess the strength of evidence supporting the use of each measure as a standard for AKI care.

Education in Nephrology Fellowship: A Survey-Based Needs Assessment.

Educational needs assessments for nephrology fellowship training are limited. This study assessed fellows' perceptions of current educational needs and interest in novel modalities that may improve their educational experience and quantified educational resources used by programs and fellows. We distributed a seven-question electronic survey to all United States-based fellows receiving complimentary American Society of Nephrology (ASN) membership at the end of the 2015-2016 academic year in conjunction with the ASN Nephrology Fellows Survey. One third (320 of 863; 37%) of fellows in Accreditation Council for Graduate Medical Education-accredited positions responded. Most respondents rated overall quality of teaching in fellowship as either "good" (37%) or "excellent" (44%), and most (55%) second-year fellows felt "fully prepared" for independent practice. Common educational resources used by fellows included UpToDate, Journal of the American Society of Nephrology/Clinical Journal of the American Society of Nephrology, and Nephrology Self-Assessment Program; others-including ASN's online curricula-were used less often. Fellows indicated interest in additional instruction in several core topics, including home dialysis modalities, ultrasonography, and pathology. Respondents strongly supported interventions to improve pathology instruction and increase time for physiology and clinical review. In conclusion, current nephrology fellows perceive several gaps in training. Innovation in education and training is needed to better prepare future nephrologists for the growing challenges of kidney care.

Enhancing Nephrology Career Interest through the ASN Kidney TREKS Program.

The Kidney Tutored Research and Education for Kidney Students (TREKS) Program is a product of the American Society of Nephrology (ASN) Workforce Committee that seeks to connect medical and graduate students to nephrology. This program starts with a weeklong camp-like course introducing participants to renal physiology through classic and modern experiments. Next, each student is matched with a nephrology mentor at his or her home institution to foster a better understanding of a nephrology career. Lastly, the students are encouraged to participate in scholarly activities and attend the ASN Kidney Week. Now in its third year, with a total of 84 participants, survey data suggest early success of the program, with a self-reported 40% increased interest in nephrology fellowship and/or research careers. In addition, students give high ratings to the course components and mentorship pairings. Continued student tracking will be necessary to determine the long-term program effect.

Improving the Nephrology Match: the Path Forward.

The Fellowship Match process was designed to provide applicants and program directors with an opportunity to consider all their options before making decisions about post-residency training. In a Match, applicants can choose the programs that best suit their career goals, and program directors can consider all candidates before preparing a rank order list. The Match is a contract, requiring obligations of both programs and applicants to achieve success, ensure uniformity, and standardize participation.

Severity of Anemia Predicts Hospital Length of Stay but Not Readmission in Patients with Chronic Kidney Disease: A Retrospective Cohort Study.

The aim of this study was to examine the relationship of severe anemia to hospital readmission and length of stay (LOS) in patients with chronic kidney disease (CKD) stage 3-5. Compared with the general population, patients with moderate CKD have a higher hospital readmission rate and LOS. Anemia in patients with moderate CKD is associated with higher morbidity and mortality. The influence of anemia on hospital outcomes in patients with moderate CKD has not been characterized.We conducted a retrospective cohort study at Maine Medical Center, a 606-bed academic tertiary care hospital. Patients with CKD stages 3-5 and not on dialysis admitted during February 2013 to January 2014 were eligible. Patients with end stage renal disease on hemodialysis or peritoneal dialysis, kidney transplant, acute kidney injury, gastrointestinal bleeding, active malignancy, pregnancy, and surgery were excluded. The cohort was split into severe anemia (hemoglobin ≤9  g/dL) versus a comparison group (hemoglobin >9 g /dL), and examined for differences in 30-day hospital readmission and LOS.In this study, the data of 1141 patients were included, out of which 156 (13.7%) had severe anemia (mean hemoglobin 8.1 g/dL, SD 0.8). Severe anemia was associated with increased hospital LOS (mean 6.4 (SD 6.0) days vs mean 4.5 (SD 4.0) days, P < 0.001). The difference was 1.7 day longer (95% CI 0.94, 2.45). There was no difference in readmission rate (mean 11.5% vs 10.2%, P = 0.7).Patients with moderate CKD and severe anemia are at risk for increased hospital LOS. Interventions targeting this high-risk population, including outpatient management of anemia, may benefit patient care and save costs through improved hospital outcomes.

Propagating the nephrology research workforce: a Kidney Research National Dialogue training commentary.

The National Institute of Diabetes and Digestive and Kidney Diseases conducted the Kidney Research National Dialogue as an interactive means to formulate and prioritize research goals necessary to address the needs of patients with renal disease. This commentary summarizes the discussion and priorities arising from the training domain of the dialogue and posits three overall strategies to broaden the nephrology research workforce pipeline. The community needs to recruit and provide support for mentors in nephrology, target medical and graduate students earlier in their education for exposure to renal research, and expand the research workforce to include basic scientists from many disciplines as well as under-represented minorities.

Recruiting the next generation of nephrologists.

The nephrology physician workforce substantially expanded during the past decade, as did the number of fellowship training positions. However, the number of U.S. medical graduates choosing nephrology careers has declined precipitously. Although workforce diversity has improved, the gains are modest. Leadership in kidney disease research and innovation is threatened by significant disincentives to the pursuit of research track careers. Meanwhile, various factors challenge reliable predictions of physician workforce demand: marked growth of the CKD and ESRD populations, shifting health care economics and access, restricted opportunities for international medical graduates, expansion of advanced practitioner utilization, and aging of the contemporary practicing physician cohort. Changing demographics and cultural shifts, including perceptions of work-life balance and quality of life, increasingly influence medical student and resident career choices. Negative student and resident attitudes toward core nephrology educational experiences and perceptions of nephrology careers are disquieting. The American Society of Nephrology has initiated a series of programs aimed at renewing interest among students and residents in nephrology careers and research training and continuing to improve the diversity of the nephrology workforce, both critical to ensuring there will be enough nephrologists to care for a growing kidney disease population.

Why not nephrology? A survey of US internal medicine subspecialty fellows.

BACKGROUND: There is a decreased interest in nephrology such that the number of trainees likely will not meet the upcoming workforce demands posed by the projected number of patients with kidney disease. We conducted a survey of US internal medicine subspecialty fellows in fields other than nephrology to determine why they did not choose nephrology. METHODS: A web-based survey with multiple choice, yes/no, and open-ended questions was sent in summer 2011 to trainees reached through internal medicine subspecialty program directors. RESULTS: 714 fellows responded to the survey (11% response rate). All non-nephrology internal medicine subspecialties were represented, and 90% of respondents were from university-based programs. Of the respondents, 31% indicated that nephrology was the most difficult physiology course taught in medical school, and 26% had considered nephrology as a career choice. Nearly one-fourth of the respondents said they would have considered nephrology if the field had higher income or the subject were taught well during medical school and residency training. The top reasons for not choosing nephrology were the belief that patients with end-stage renal disease were too complicated, the lack of a mentor, and that there were insufficient procedures in nephrology. CONCLUSIONS: Most non-nephrology internal medicine subspecialty fellows never considered nephrology as a career choice. A significant proportion were dissuaded by factors such as the challenges of the patient population, lack of role models, lack of procedures, and perceived difficulty of the subject matter. Addressing these factors will require the concerted effort of nephrologists throughout the training community.

The challenge of methicillin-resistant Staphylococcus aureus prevention in hemodialysis therapy.

Methicillin-resistant Staphylococcus aureus (MRSA) infections have challenged care process and resource utilization in the acute hospital care setting for nearly 30 years. These infections have become important causes of morbidity, mortality, and a source of concern in the primary and emergency care context over the past decade. As individuals receiving recurrent therapy with features of both ambulatory care and acute care, hemodialysis patients are exposed to numerous opportunities for MRSA acquisition. Surprisingly, high prevalence rates for MRSA colonization have been demonstrated for both hemodialysis patients and their care providers. The necessity of vascular access and the persistent high prevalence of endovascular catheter use among patients repeatedly exposed to healthcare settings provide the perfect milieu for the troubling rates of MRSA infection, particularly bloodstream infections, in outpatient dialysis care. Dialysis industry shifts, including increased requirements for compliance and reporting in other areas of dialysis care, tax resources for infection prevention processes. Multifaceted strategies that include reassessment of vascular access care, attention to the interruption of MRSA transmission dynamics, and emphasis on organizational learning processes are needed to accomplish a meaningful reduction in the morbidity, mortality, and cost associated with MRSA infections in dialysis care.

The future nephrology workforce: will there be one?

Interest in nephrology as a career is declining and has been on the decline for nearly one decade. From 2002 to 2009, all internal medicine subspecialties except geriatric medicine increased the number of available fellowship positions. However, only two subspecialties attracted fewer United States medical graduates (USMGs) in 2009 than in 2002: geriatric medicine and nephrology. This drop occurred at a time when demand for nephrologists is increasing and when the specialty is having a harder time benefiting from the substantial contribution of international medical graduates (IMGs). Today's USMGs possess fundamentally different career and personal goals from their teachers and mentors. Medical students report receiving minimal exposure to nephrology in clinical rotations, and they perceive that the specialty is too complex, uninteresting, and lacks professional opportunity. Meanwhile, the demographics of kidney disease in the United States, as well as recent national health policy developments, indicate a growing need for nephrologists. Efforts to improve the educational continuum in nephrology and enhance mentorship are essential to restoring interest in nephrology for USMGs, maintaining its appeal among IMGs, and developing a workforce sufficient to meet future demand for renal care.

Safety of low volume iodinated contrast administration for arteriovenous fistula intervention in chronic kidney disease stage 4 or 5 utilizing a bicarbonate prophylaxis strategy.

Efforts to increase the number of functioning arteriovenous fistulas in chronic kidney disease (CKD) stages 4 and 5 have been impacted by concerns about the risk for contrast-induced nephropathy during diagnostic and interventional procedures for poorly developed fistulas. We conducted a prospective observational study of low volume iodinated contrast administration for fistulography and angioplasty in a CKD stage 4 and stage 5 population pretreated with a sodium bicarbonate protocol. Acute kidney injury was assessed by change in serum creatinine and urinary neutrophil-gelatinase associated lipocalcin (NGAL). Only 1/18 patients (5.5%) developed acute kidney injury as defined by change in serum creatinine 48 hours after contrast exposure. No patients demonstrated significant change in urinary NGAL at 3 or 48 hours after procedure, nor did any require acute initiation of dialysis. Fistulography alone, or with angioplasty, utilizing a low volume of iodinated contrast and sodium bicarbonate solution for prophylaxis, appears to be safe in the CKD stages 4 and 5 population.

Nephrology training in the 21st century: toward outcomes-based education.

Twentieth century postgraduate nephrology training evolved from an apprenticeship model to a defined period in formal fellowship. Subsequently, curriculum content taught by an engaged faculty, including broad clinical exposure, literature review, and investigative experience, established the benchmark of quality education. Self-directed study by the trainee was emphasized, and competence to practice nephrology was presumed in part on the basis of adequate exposure to a program's curriculum. At the close of the century, multiple accreditation bodies of medical education questioned the validity of this educational process in medical training. As a result, the Accreditation Council for Graduate Medical Education instituted 6 general competencies as the foundation of an outcomes-based education philosophy. Although some disciplines have developed an evidence base for educational techniques directed at outcomes, nephrology has few publications in this arena and these principally address curriculum structure. Interventional nephrology is a recent exception. In this area of training, publications have appeared linking educational process with learner outcome. Opportunities are abundant to implement and study new educational techniques, including simulation and e-learning. To keep pace with contemporary medical education philosophy, the nephrology education community is challenged to apply evidence-based education techniques to the training of 21st century nephrologists.