Using Physician Extenders to Create a CKD Clinic Theresa Becker, MSN, APNP Midwest Nephrology Assoc. Chronic Kidney Disease Clinic
CKD Clinic The ideas of: • Linking CKD Clinics & Anemia Management Programs • Using physician extenders in a multidisciplinary approach Are not new!
CKD Clinic ADEPT Clinic • Arizonia Disease Education Prevention & Treatment • Started as an anemia management clinic but soon developed into a CKD Clinic • Patients are referred to the Vascular Access Program when GFRs are 25-30 mL/min. Curtis C, Yee B. The process of implementing a CKD Clinic Nephrology News & Issues. 2005;19:53-54.
CKD Clinic SHAPE UP Program • Staging & Smoking Cessation • Hypertension, Hyperglycemia, Hyperlipidemia, Hyperphosphatemia, Hyperparathyroidism, Hyperkalemia, & Hypervolemia • Anemia • Proteinuria • Evaluation for KRT • Undo nephrotoxins • Preservation of veins & Patient education Gnanasekaran I, Kim S, Dimitrov V, Soni A. SHAPE UP-A management program for chronic kidney disease Dialysis & Transplantation. 2006;35: 294-302.
CKD Clinic One step further : • A study by Curtis et al. suggested that even after appropriate & timely referral to a nephrologist, there is additional value of a multidisciplinary team approach in optimizing both short and long term patient outcomes. Curtis BM, Ravani P, Malberti F, et al. The short and long term impact of multi- disciplinary clinics in addition to standard nephrology care on patient outcomes. Nephrol Dial Transplant. 2005;20:147-154.
CKD Clinic Midwest Nephrology Associates CKD Clinic Model
CKD Clinic Components of the CKD Care Plan GFR < 60 ml/min. • HTN • Anemia • Nutritional Status/DM • Bone/Mineral Metabolism • Neuropathy • Functioning & Well-being • Delaying Progression of CKD
CKD Clinic Components of the CKD Care Plan GFR < 30 ml/min. • Review Modality Options • Preparation for chosen option • Transplant referral GFR < 15 ml/min. • Tour Clinic • Monitor for ESRD signs & symptoms
CKD Clinic CKD Patient Education Topics • CKD and consequences; anemia and bone disease • Common medications used in CKD • Avoidance of nephrotoxic agents • KRT Modalities • Arm Preservation for HD access, Access placement & care of site • Healthy living
CKD Clinic Access Teaching • Pre AV access: Evaluation for appropriate arm such as vein mapping and instruction on saving that arm. • Post AV access: Care of the site, exercising the access, and monitoring its development as well as instruction on its future use.
CKD Clinic Documentation • Medication List • Clinical Action Plan • Health Maintenance • Clinic Note • Surgical Referral Form • Vascular Access Record • Chart Label
CKD Clinic Surgical Referral Form Date: __________________ Surgeon: __________________________ Phone: ______________ Fax: ________________ Patient: _________________________________________________ DOB: _______________ Nephrologist: ________________________ Phone: ______________ Fax: _______________ PCP: ______________________________ Phone: _______________ This patient is being referred to you for access placement. The desired access is an AV Fistula. In the event you are not planning to place an AV Fistula in this patient, please call the nephrologist prior to placing any other access. Patient’s non-dominant are is: Right Left Patient has been saving the following arm: Right Left Comments (ie: arm injury/mastectomy/pacemaker/previous access): Vein Mapping done pre-referral: No Yes – Date/Location: ______________________ Patient is currently on dialysis: Days: ____________________________________________________________________ Location/Phone: ____________________________________________________________ Patient is not on dialysis at this time: Anticipated hemodialysis start date: _______________________ months Most recent serum creatinine: ________ mg/dL & Creatinine Clearance/GFR: ________ ml/min Patient is on Anti-Coagulant Therapy: No Yes ___________________________________ Allergies: NKDA Yes _______________________________________________________ The following patient information is also enclosed: Face Sheet Vein Mapping Report H & P Recent Labwork Medication List
CKD Clinic Vascular Access Record Stage 4 (GFR < 30 ml/min): Surgical consult should be for ‘AVF Only’. • Instruct Patient to Preserve Veins of Non-Dominant or Appropriate Arm • Obtain Vein Mapping • KDOQI Benchmark: AVF placement of > 65% for prevalent patients.
CKD Clinic Surgeon ___________________ Date _______________
CKD Clinic Chart Label
CKD Clinic AVF Statistics Patients Initiating HD 1/1/06 to 10/31/06
CKD Clinic Vaccination Statistics 7/1/06 to 12/31/06
CKD Insurance Issues CPT Office Visit Billing Codes • Low complexity visit (~ 15 min.) – 99213 • Moderate complexity visit (~ 25 min.) – 99214 • High complexity visit (~ 40 min.) – 99215
CKD Insurance Issues ICD 9 Office Visit Billing Codes • CKD Stage 1 (GFR > 90) – 585.1 • CKD Stage 2 (GFR 60-89) – 585.2 • CKD Stage 3 (GFR 30-59) – 585.3 • CKD Stage 4 (GFR 15-29) – 585.4 • CKD Stage 5 (GFR<15) – 585.5
CKD Insurance Issues Office Visit Reimbursement • Commercial Insurances reimburse NPs at 100% of MD charges • Medicare only reimburses NPs at 80% of MD charges • Medicare and a secondary insurance reimburses NPs at 100% of MD charges
Anemia Management Program Erythropoietin Stimulating Agents (ESA) Available for Stage 1 – 5 CKD Patients McClellan, Schoolwerth A., Gehr, T. Clinical Management of Chronic Kidney Disease. Cadido, OK: Professional Communications, Inc.; 2006:185-208.
ESA Agents Aranesp Package Insert Amgen®
ESA Agents Side Effect Profile • HTN and Headaches • Myalgias • Diarrhea Contraindications • Uncontrolled HTN • Known hypersensitivity to the active substance or any of the excipients
ESA Agents FDA Black Box Warning Issued 3/9/07 • Use the lowest dose of ESA that will gradually increase the Hgb concentration to the lowest level sufficient to avoid the need for RBC transfusion. • ESAs increase the risk for death and serious CV events when administered to target a Hgb > 12 gm/dL.
RPA Renal Physicians Association Risks and benefits must be on individual patient basis Evidence based Hgb targets are helpful and should be reintroduced May lead to unacceptably low Hgb levels AAKP American Association of Kidney Patients Warning may be confusing to patients & providers Supports targeting Hgbs between 11 and 12 Lower Hgb lead to concerns regarding QOL ESA Agents
ESA Agents Epoetin alfa (Procrit) Single-Dose Preservative Free Vials • 2,000 units, 3,000 units, 4,000 units, 10,000 units, 40,000 units/1 mL Multi-Dose Preserved Vials • 20,000 units/1 mL • 20,000 units/2 mL
ESA Agents Darbepoetin alfa (Aranesp) Single-Dose Preservative Free Vials • 25 mcg, 40 mcg, 60 mcg, 100 mcg, 200 mcg, 300 mcg, 500 mcg/1 mL • 150 mcg/0.75 mL
ESA Agents Darbepoetin alfa (Aranesp) Single-Dose Prefilled Syringes • 25 mcg/0.42 mL • 40 mcg/0.4 mL • 60 mcg/0.3 mL • 100 mcg/0.5 mL • 150 mcg/0.3 mL • 200 mcg/0.4 mL SingleJect Syringe SureClick Syringe
ESA Utilization Guidelines • Hgb Level of < 11.0 gm/dL within 30 days • T. Sat. and/or Ferritin within 30 to 90 days • Serum creatinine within 30 days • Patient’s weight in kilograms • ESA Dose per kilogram • Erythropoietin level is NOT recommended
ESA Utilization Guidelines • Target Hgb at or above 11.0 gm/dL • Caution when intentionally maintaining Hgb > 13.0 gm/dL • Monitor Hgb minimum of every 30 days • Target Ferritin > 100 ng/mL and T. Saturation > 20% • Monitor Iron Indices Quarterly
ESA Utilization Guidelines Dose Adjustments • If Hgb increases by > 2 gm/dL per 4 weeks and/or Hgb level > 12 gm/dL, decrease dose by 20 to 25% • If Hgb level is increasing < 1 gm/dL per 4 weeks, increase dose by 20 to 25%
ESA Utilization Guidelines Dose Adjustments 20 to 25% dose adjustments may be achieved by: • Altering the ESA dose • Altering the time interval between injections
ESA Utilization Guidelines Dose Adjustments • Increases in dose should not be made more frequently than once a month. • Avoid holding doses to avoid marked drop in ESA sensitive RBC precursors and the ‘seesaw’ effect of Hgb poor response pattern.
ESA Utilization Guidelines Dose Adjustments More frequent Hgb &/or iron indices monitoring may be necessary when: • Recent bleeding or surgery • Post hospitalization • Post IV iron course • Periods of ESA hypo-response
ESA Utilization Guidelines ESA Resistance • Infection/Inflammation • Blood Loss, Guiac Positive Stools • Hyperparathyroidism • B12, Folate Deficiencies • Sickle cell, Thalacemias • Multiple Myeloma/Malignancy • ACE Inhibitor Use
ESA Utilization Guidelines Dose Adjustments • Recent data indicates Hgb levels can be maintained with every two week epoetin alfa dosing and monthly darbepoetin alfa dosing. • Benefits include increased staff productivity and patient satisfaction/compliance. Moore T., Chookie S. Extended dosing od darbepoetin alfa in patients with chronic kidney disease not on dialysis: A review of recent data. Journal of ANNA 2005;32:399-407.
ESA Utilization Guidelines Medicare considers doses exceeding 90,000 units per week for epoetin alfa or 200 mcg per week for darbepoetin alfa to be rarely reasonable and necessary. Medical justification for doses exceeding these amounts should be documented in the patient’s record.
ESA Utilization Guidelines ESA Flowsheet
Hemoglobin Monitoring HemoCue vs. Lab Draw • HemoCue Analyzer utilizes an optical measuring microcuvette. It provides nearly instantaneous Hgb results with very good accuracy. • Traditional Lab Draw may be used. However, it will require another appointment or extended patient visit while awaiting lab results.
Hemoglobin Monitoring • HemoCue Analyzer HemoCue Inc. 40 Empire Drive Lake Forest, CA 92630 Phone: 1800.881.1611 Fax: 1800.333.7043 www.hemocue.com • HemoCue machines require a CLIA (Clinical Laboratory Improvement Amendment) Certificate of Waiver www.cms.hhs.gov/clia/
ESA Insurance Issues CPT ESA Billing Codes • Epoetin alfa – J0885 (Standard unit 1,000 units) • Darbepoetin alfa - J0881 (Standard unit 1 mcg) • Injection – 90772 • HemoCue Lab – 85018QW
ESA Insurance Issues ICD 9 ESA Billing Codes • Anemia – 285.9 • CKD Stage 1 (GFR > 90) – 585.1 • CKD Stage 2 (GFR 60-89) – 585.2 • CKD Stage 3 (GFR 30-59) – 585.3 • CKD Stage 4 (GFR 15-29) – 585.4 • CKD Stage 5 (GFR<15) – 585.5
ESA Insurance Issues Benefit Determination • Billing Office Review of Patient’s Insurance • Procit – PROCRITline 1800.553.3851 or www.procritline.com • Aranesp – Amgen Reimbursement Connection 1800.272.9376 or www.reimbursementconnection.com
ESA Insurance Issues Benefit Assistance • HealthWell Foundation P.O. Box 4133 Gaithersburg, MD 20885-4133 Phone: 1800.675.8416 Fax: 1800.282.7692 www.healthwellfoundation.org
ESA Insurance Issues Drug Assistance • Drug company vouchers which generally allow one month supply of ESA • ESA samples may be available
ESA Self Administration Initial Teaching • ESA script must include Anemia & CKD Stage ICD 9 codes • Instruct patient on storage, handling, and observe administration of ESA • Office visit charge
ESA Self Administration Monitoring • Monthly HemoCue lab charge vs. traditional lab draw • Office visit charge
New Agents Mircera • Developed by Roche • First and only Continuous Erythropoietin Receptor Activator (C.E.R.A.) • Twice monthly dosing schedule, however generally will be able to administer monthly yet maintain stable Hgb levels • IV/SC administration • May be used in CKD & dialysis patients
IV Iron Iron Sucrose (Venofer) • 100 mg/1 mL vial • Administer 200 mg slow IV infusion over 2 to 5 minutes on 5 different occasions within a 14 day period. Typically dosed weekly for 5 weeks. • Generally administered when Ferritin < 100 ng/mL and/or T. Saturation < 20%