Kaiser Permanente’s ‘optimal starts’ program gives patients choices that can reduce complications and enhance quality of life
“Fear is the big thing when you learn your kidneys aren’t working and you will need dialysis,” says Kaiser Permanente Southern California member Liz Simmons. “I had made bad choices regarding my health and took it for granted.”
Kidney failure is a serious risk for one in seven Americans who have chronic kidney disease, chiefly due to diabetes and high blood pressure. Often in its early stages there are no symptoms so kidney damage can progress undetected and irreversibly over many years.
“What we want is to avoid abrupt kidney failure when we can,” says Philip Madvig, MD, associate executive director, The Permanente Medical Group and national lead for the end stage renal disease clinical quality initiative. “Patients want to think kidney failure will never happen, but what makes a difference is anticipating it months in advance and getting an early start to be ready for replacement therapy.”
Kaiser Permanente is outperforming the nation — at twice the U.S. average — in “optimal starts" (beginning replacement therapy early, before kidneys fail completely) in patients with end-stage renal disease. These results are thanks to the work of Kaiser Permanente’s interregional nephrology group, which for the past six years has been working to address the challenge of intervening early by looking at how patients start on dialysis.
Often, by the time patients realize they need dialysis, they are already in the late stage of kidney disease, and emergency dialysis carries with it serious risks of infection and complications.
“We will never be able to anticipate 100 percent of the time because kidney failure is sometimes sudden due to severe infection, critical illness or trauma,” says Leo Pravoverov, MD, current chair of the interregional nephrology group and medical director of Kaiser Permanente Northern California end stage renal disease contracted services. “But our goal is to provide patients with the best possible options in the transition from chronic kidney disease to end stage renal disease, and there are now sophisticated therapies that can be managed at home.”
Kaiser Permanente members facing kidney failure have a multi-specialty care team to support them and three options for an optimal start. They can choose between two types of dialysis to replace the filtering role their kidneys performed — peritoneal dialysis at home or hemodialysis at home or in a dialysis center — or for some patients, a preemptive kidney transplant.
Peritoneal dialysis is a procedure that patients can manage alone or with the help of family each night at home. It uses the peritoneal membrane, or lining of the abdominal cavity, to filter wastes from the blood by attaching a catheter in the abdomen to a high-tech machine about the size of a small suitcase that processes fluid exchange. The procedure is common outside the U.S. and gaining popularity here. It has the advantages of fewer complications than going to a dialysis center and greater flexibility and autonomy, with daytime hours free for work and other activities, and is portable enough for travel.
“With home peritoneal dialysis I can have the quality of life that I had — and want,” said Liz Simmons. “I co-own a business and work full time and needed something that didn’t interfere with my life, and I’m able to travel and that’s included going on six cruises and to Europe several times.”
Hemodialysis at home or in a dialysis center through a fistula in the arm is another optimal-start option. The fistula, a surgically-created union of an artery and vein, is connected to a dialysis machine that cleanses the blood of waste and sends clean blood back into the body.
Kaiser Permanente Northern California member Annette Madden has experienced the full range of dialysis options: in-center hemodialysis for six months, peritoneal dialysis for 11 years, and home hemodialysis for the last seven and a half years.
“I had to start in a center, but dialysis in a room with lots of people hooked up to machines felt very medical. I researched it and moved to peritoneal dialysis every night. Now I’m doing home hemodialysis every other night which gives me a day off and I feel better.”
A third early start option for some patients is a preemptive kidney transplant. As with later-stage transplants after a patient has been on dialysis, this option is limited by a person’s health status and the availability of a kidney from a living or deceased donor.
“Kaiser Permanente’s optimal starts program for end stage renal disease is an example of what our Kaiser Permanente care model enables us to,” says Peter Crooks, MD, founding chair of the interregional nephrology group and Southern California Permanente Medical Group partner emeritus.
“The optimal starts program really emphasizes early education and decisionmaking,” says Kaiser Permanente Northern California nephrology case manager Katherine Wilson. It takes planning and an interdisciplinary team, including nursing care coordinators to educate patients and families about the options, plan the timing and sequence of steps, and provide regular ongoing support.
When home dialysis is selected, there’s also a home visit and training. “It usually takes five to 10 half days to learn the procedure and sterile technique for dialysis at home,” said Alan Falcioni, peritoneal coordinator at Kaiser Permanente Southern California Ontario Medical Center, “and we have found that individualized training is most effective.”
“Our performance is superior to what happens in most of the United States,” says Dr. Crooks, “and we are pleased that Kaiser Permanente’s optimal starts measure has been adopted by the National Quality Forum as a national voluntary consensus standard for federal health programs and health plans.”