The changing landscape of PAs and NPs in nephrology.

BACKGROUND: Physician assistants (PAs) and NPs have expanded roles in nephrology as both the patient load and acuity of care needed for this population have increased. PURPOSE: To evaluate the workforce patterns of PAs and NPs working in nephrology over the past decade. METHODS: Using the biannual survey from the National Kidney Foundation Council of Advanced Practitioners, data were collected and analyzed over the past decade. RESULTS: Surveys of nephrology practitioners show the evolution of the dialysis-focused practitioner to one encompassing all aspects of nephrology: hospital, ICU, research, office, and all types of dialysis. Salaries and benefits have increased to compensate for the expansion of responsibilities. CONCLUSIONS: PAs and NPs in nephrology have the opportunity to use their skills and training in caring for this high-risk population.

Reevaluating race and the glomerular filtration rate calculator.

ABSTRACT: Estimated glomerular filtration rate (eGFR) calculators have included a race adjustment to help approximate measured GFR. Over the past several years, as more attention has been directed toward uncovering racial bias, the appropriateness of including race in these calculators has been called into question. The American Society of Nephrology and the National Kidney Foundation convened an expert task force to review the inclusion of race in eGFR. The deliberative review showed that race can be removed from eGFR calculators without causing adverse reactions in any group of patients. This new, refitted CKD-EPI equation can be used immediately by all laboratories in the United States. The task force also recommended greater use of cystatin C nationally in eGFR calculations. This would enable the new CKD-EPI equation to incorporate both creatinine and cystatin C without race and would yield better accuracy than a calculator that uses creatinine alone.

Improving health disparities in PA practices: A quality improvement initiative.

OBJECTIVE: To assess a quality improvement initiative designed to highlight awareness of health disparities and improve healthcare practices among participants. METHODS: Data were collected from 102 clinically practicing PAs over a 2-year timespan via the quality improvement initiative Outside the Box: Reducing Health Disparities. As part of the program, participants reviewed 10 random charts in their practice, documenting how they identified and/or managed common health disparities. Then, participants reviewed the educational materials provided and implemented practice-specific interventions. Thirty days after the initial review, a second random review of charts was executed. RESULTS: Postintervention results showed statistically significant moderate- to large-sized quality improvement across most categories. CONCLUSIONS: This study demonstrates that Outside the Box participation was associated with practice quality improvements among participants in several domains that are known to experience health disparities. Results suggest that increasing awareness of ideal professional behaviors can result in quality improvements in practices.

Longitudinal survey of clinician behavior change in CKD management.

OBJECTIVE: To assess longitudinal improvement for a simple intervention to teach physician assistants (PAs) and NPs management of patients with diabetes and chronic kidney disease (CKD). METHODS: The original cohort from the Kidneys in a Box quality improvement project was revisited at the 3-year mark and asked about patient statin use, A1C measurement, urine albumin-creatinine ratio (UACR), CKD staging, distribution of over-the-counter (OTC) medication caution lists, and documentation of smoking history. RESULTS: A statistically significant increase in quality metrics was seen at 3 months postintervention for the original cohort. At the 3-year mark, these improvements were sustained. For UACR and smoking quality metrics, performance increased beyond the gains initially seen at 3 months. CONCLUSIONS: This study demonstrates that a single-intervention quality improvement program can affect sustained improvements in clinical care of patients with diabetes and CKD. The results provide evidence that one-time quality improvement interventions have the power to promote longitudinal practice changes associated with reduced rates of CKD progression and potentially reduced healthcare costs.

The ABCs of chronic kidney disease.

Management of patients with chronic kidney disease has evolved since the last Kidney Disease Improving Global Outcomes clinical practice guideline was published in 2012. This article reviews the most recent guidelines, common management issues in primary care, kidney risk and outcome calculators, and over-the-counter medications that may cause community-acquired acute kidney injury.

Acute kidney injury.

Acute kidney injury (AKI) complicates up to 20% of all hospital admissions. Responding to the increase in admissions, complications, mortality, morbidity, and cost of AKI, Kidney Disease: Improving Global Outcomes convened an expert panel to study the issue, review the literature, and publish guidelines to evaluate and treat patients with AKI in the acute setting. This article reviews those guidelines.

Improving treatment for patients with chronic kidney disease.

OBJECTIVE: Kidneys in a Box (KIB) was developed to identify the effect of a performance improvement CME (PI-CME) project on the management of patients with diabetes who are at risk for chronic kidney disease (CKD). The program provided nonnephrology practitioners with research-based interventions known to slow CKD progression. METHODS: PAs were given the KIB tool kit, which described the scope of CKD identified high-risk diagnoses such as diabetes, and listed six modifiable risk factors that have been shown to slow progression of diabetic kidney disease when implemented. The PAs self-selected the factor(s) and evaluated 10 charts of patients diagnosed with diabetes before implementing the modifications. After implementing changes for a minimum of 12 weeks, the PAs again self-selected 10 different charts and evaluated the extent of the intervention application. A preintervention/postintervention assessment and demographic sheet were then submitted to the American Academy of Nephrology PAs for CME credit. RESULTS: 302 PAs completed the program in the first 24 months, with full data available for 213 PAs. Statistically significant improvement was shown in five of the six areas: CKD staging, urine albumin-creatinine ratio (UACR), statin use, over-the-counter (OTC) yellow alert medications, and A1C. Improvement in smoking cessation interventions did not reach statistical significance. CONCLUSIONS: Known interventions to slow progression of diabetic kidney disease can be effective if implemented in early stages of the disease. KIB demonstrates that education focused on the nonnephrology PA can be effective in slowing CKD progression.

Kidney care beyond our borders.

Whether it is the heartland of America or a remote village in a developing country, one overriding theme to providing care for kidney patients is person power--or the lack of it. In the developed countries, notably the U.S., Australia, New Zealand and Europe, medical schools prepare advanced practitioners who can then fill the gap left by the lack of nephrologists. However in areas where physicians are in short supply, nurses often have only basic training and trained APs are not available. In the meantime, kidney disease is taking its toll on the best and the brightest.

Nursing homes: The new frontier.

As the population continues to age, we will see a larger percentage of end-stage CKD patients in nursing homes, both skilled and long-term facilities. This is a fragile population and will take buy-in from all practitioners to care for them. Even with the dietitian to manage a complicated and detailed menu, the social worker to manage the transportation and multiple issues with equipment, the therapy staff to protect against loss of ADLs, the recreational therapist to protect against loss of cognitive function and the medical staff (APs, nursing, physicians), this population will continue to present both challenges and opportunities.

Transplant in the 21st century.

Organ transplantation has enriched and prolonged the lives of many patients who otherwise would have died of organ failure. Many of these advances, which occurred in the later part of the 20th century, are due to improved techniques and pharmacological management. Today, almost every organ can be transplanted. However, donor and recipient criteria can vary widely according to the organ(s) in question. This article reviews the historical changes that have occurred in transplant along with current criteria for donors and recipients, and describes the newest outreach to increase the donor pool.

Managing hypertension in patients with chronic kidney disease.

Chronic kidney disease (CKD) and hypertension are intrinsically linked. Although 59% of the US population will be diagnosed with CKD during their lifetimes, mortality is usually due to a cardiovascular event. Sodium restriction and a combination of a renin-angiotensin-aldosterone medication and a calcium channel blocker are the most effective methods of managing hypertension in patients with CKD.

Staying up to date with the JNC 8 hypertension guideline.

The recently released JNC 8 guideline on hypertension management is a major departure from previous JNC guidelines in methodology, focus, and content. This article reviews the design and content of the new guideline as well as its similarities and differences from JNC 7 and other recently published hypertension guidelines.

Kidney disease education: A niche for PAs and NPs.

OBJECTIVE: This study evaluated the number of Stage 4 chronic kidney disease (CKD) education classes taught by physician assistants (PAs) and NPs. METHODS: Descriptive analysis of data from the CMS Public Use File were calculated for 2010-2011 kidney disease education classes with particular focus on PAs and NPs. RESULTS: In 2010, 4,580 individual and 1,612 group classes were held; one-third of individual classes and two-thirds of group classes were taught by PAs and NPs. In 2011, with a 32% increase in classes, the percentages of PA and NP instructors stayed the same. PAs and NPs predominantly teach home classes, group classes, and outpatient hospital classes. CONCLUSIONS: Less than 7% of eligible patients were offered education classes in 2010-2011. An examination of Medicare billing data shows PAs and NPs are underused in patient education, an area in which they are uniquely qualified.

Updated guidelines for managing chronic kidney disease.

Chronic kidney disease (CKD) is the most costly disease covered by Medicare, and two common causes of CKD, diabetes and hypertension, are increasing worldwide. More than 60% of Americans will develop CKD in their lifetimes. This article reviews updated guidelines for managing CKD in primary care.

Medication dosing in patients with chronic kidney disease.

Appropriate dosage adjustments for patients with chronic kidney disease (CKD) are critical for patient safety. This article reviews adjustments for common antidiabetic, antibiotic, analgesic, and antithrombotic medications, as well as important patient teaching information for over-the-counter (OTC) medications.

Postgraduate Education and Training for the Nephrology Physician Assistants and Nurse Practitioners.

There is no consistent educational model to introduce the physician assistant and/or nurse practitioner to nephrology. The job descriptions of the nephrology physician assistant/nurse practitioner may be similar, but the training, state and federal licensing, background, and recertification are different for the 2 professions adding a level of complexity to the training of the physician assistant/nurse practitioner new to nephrology. On-the-job training is the most common modality, but formats, content, mentors, and practices vary from organization to organization and even within organizations. The advantage of on-the-job training is its flexibility while the disadvantage is its nonspecific outcomes. As nephrology practices vary widely and range from single provider private practices to multiprovider academic practices, it is difficult if not impossible to develop a generic orientation model. This article outlines the history and present state of postgraduate educational offerings for the physician assistant/nurse practitioner and provides insight into components of an ideal training program.