Patient Education: Why Do So Few CKD Patients Receive Patient Education
People with chronic kidney disease (CKD) face multiple challenges from needing to learn a whole vocabulary of medical terms, diet and medication regimen including what to take and what to avoid, what are healthy and unhealthy behaviors, and more to improve their chances of positive outcomes. There is no question about the benefits of CKD education. Research has consistently reported benefits including but not limited to:
Better blood pressure control2
HD patient starts dialysis using a permanent HD access3
Maintain kidney function longer postponing the need for dialysis4
In 2010, Medicare started paying for up to six kidney disease education classes for those with Medicare who have Stage IV CKD (eGFR 15-29 ml/min/1.73m2) when the education is provided by a “qualified” provider (physician, clinical nurse specialist, nurse practitioner, or physician assistant), lasts at least 31 minutes, is provided to individual patients (CPT code G0420) or to 2-20 patients in a group (CPT code G0421), and includes an outcome assessment. CMS now allows KDE services to be offered by telehealth using an interactive audio and video communications system permitting real-time communication between the provider and Medicare patient.8 In my state (Kansas), Medicare’s allowed charge is $106.42 for an individual KDE session and $24.57 per patient for a group KDE session.9 NOTE: Patients with CKD can have Medicare and qualify for KDE services if they have sufficient work history and legal status and are 65 or older or have received Social Security Disability Insurance (SSDI) payments for at least 24 months.
Narva et al. described barriers to CKD education. Patient barriers included “low baseline awareness of CKD, health literacy and numeracy, access to information on CKD, and readiness to learn.” Provider barriers included “poor prioritization of CKD, time constraints, lack of confidence, challenges communicating the complexity of CKD, competing demands, and lack of consensus regarding the timing and appropriateness for initiating CKD education.” System barriers included “limited incentives for education, lack of decision support, and inadequate interdisciplinary care models.”10
Some of the perceived barriers listed above aren’t real—and some of the real barriers can be overcome with enough effort. Several organizations, including the American Association of Kidney Patients, Medical Education Institute, the National Kidney Disease Education Program, and the National Kidney Foundation have materials to use for CKD education. There are online tools and phone apps that should help physicians stage CKD. There are KDOQI and KDIGO guidelines that recommend educating patients at CKD Stage IV. Several dialysis providers offer CKD education. The Missouri Kidney Program, which has offered free Patient Education Program classes for CKD patients in Missouri since 1983, is a model for multidisciplinary CKD education that includes professional and patient speakers. Pre and post-surveys show that MoKP PEP graduates know more and are more interested in home dialysis and/or transplant.
In spite of known benefits of education and the availability of Medicare funds to pay for CKD education, the number of CKD patients with Medicare claims for KDE is a mere drop in the bucket of all patients with CKD. According to the United States Renal Data System which responded to a data request for 2010-2015, the number of Medicare patients nationally who had a claim for either G0420 or G042111:
|Patients (5% sample) with claim for G0420 or G0421||155||218||245||187||175||178|
One of the reasons identified by Narva et al. is a lack of incentives. Is Medicare’s reimbursement too little when a physician’s office can bill more than $100 for an individual KDE session lasting only 31 minutes or can get more for 31 minutes by doing group classes with up to 20 people? How much would the return on investment be for that physician’s office if a patient is better able to self-manage, stays healthier, lives longer, and doesn’t need dialysis as soon. Or is postponing kidney failure a disincentive when so much money can be made by doctors, dialysis providers, and transplant programs after a patients’ kidneys fail? Shouldn’t patients’ interests and well-being take priority? Can we do more to encourage qualified providers to offer KDE services in-person or by telehealth? Can we do more to inform CKD patients of what’s in if for them to attend KDE sessions that might increase their motivation to attend? Or is it all about the money?
Wright Nunes JA, Wallston KA, Eden SK, Shintani AK, Ikizler TA, Cavanaugh KL : Associations among perceived and objective disease knowledge and satisfaction with physician communication in patients with chronic kidney disease. Kidney Int 80: 1344–1351, 2011↩
Wright-Nunes JA, Luther JM, Ikizler TA, Cavanaugh KL : Patient knowledge of blood pressure target is associated with improved blood pressure control in chronic kidney disease. Patient Educ Couns 88: 184–188, 2012↩
Cavanaugh KL, Wingard RL, Hakim RM, Elasy TA, Ikizler TA : Patient dialysis knowledge is associated with permanent arteriovenous access use in chronic hemodialysis. Clin J Am Soc Nephrol 4: 950–956, 2009↩
Devins GM, Mendelssohn DC, Barré PE, Binik YM Predialysis psychoeducational intervention and coping styles influence time to dialysis in chronic kidney disease. Am J Kidney Dis 42: 693–703, 2003↩
Ribitsch W, Haditsch B, Otto R, Schilcher G, Quehenberger F, Roob JM, Rosenkranz AR : Effects of a pre-dialysis patient education program on the relative frequencies of dialysis modalities. Perit Dial Int 33: 367–371, 2013↩
Manns BJ, Taub K, Vanderstraeten C, Jones H, Mills C, Visser M, McLaughlin K. The impact of education on chronic kidney disease patients’ plans to initiate dialysis with self-care dialysis: A randomized trial. Kidney Int 68: 1777–1783, 2005↩
Devins GM, Mendelssohn DC, Barré PE, Taub K, Binik YM: Predialysis psychoeducational intervention extends survival in CKD: A 20-year follow-up. Am J Kidney Dis 46: 1088–1098, 2005↩
CMS Medicare Learning Network. Telehealth services. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf (Accessed 12/5/2018)↩
CMS Physician Fee Schedule Search. https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx (Accessed 12/5/2018)↩
Narva AS, Norton JM, Boulware JE. Educating patients about CKD: The path to self-management and patient-centered care. Clin J Am Soc Nephrol 11: 694–703, 2016↩
United States Renal Data System, data request fulfilled 11/21/2018.↩