By Robert Provenzano, MD

In honor of High Blood Pressure Education Month, I’ve invited Susan Steigerwalt, MD, FACP, of St. Claire Specialty Physicians, P.C., to write a guest blog post on the topic of hypertension. If you’d like to get involved in the education process, you can join DaVita and the kidney care Twitter community as they host a Tweet Chat in honor of World Hypertension Day, which is May 17th. This online event takes place on Thursday, May 16, at 6 p.m. MT. For more information, follow the #kidneyaware hashtag.

May is National High Blood Pressure Education Month. This is a time to reflect and reenergize in the struggle to improve blood-pressure control—yours and your patients’—and review tools and resources for patients and providers. While we are still awaiting the eighth version of Managing Blood Pressure in Adults: Report from the Joint National Committee (JNC 8)—due out any month—there are important initiatives, updates and technologies that will help with improved control of blood pressure. Inadequately addressed lifestyle issues continue to get in the way of achieving control—and some of this low-hanging fruit needs to be picked!

Let’s talk about resources and initiatives first. The Centers for Disease Control and Prevention (CDC) website this month features hypertension. It has a simple explanation of hypertension and control tips, with links for patients and providers. The Million Hearts initiative from the US Department of Health and Human Services (HHS) attempts to prevent one million heart attacks and strokes over five years and includes a Facebook page and resources for healthcare providers, including pharmacists.

The HHS and CDC program “Team Up. Pressure Down.” presents simple tips for providers to improve patient adherence to therapy. This includes ways to engage patients in exposing barriers to taking medication regularly, and reminds providers about simplifying regimens (once daily) as well as assisting patients to enable them to measure blood pressure outside of the doctor’s office. Multiple studies have shown that home blood-pressure measurement with feedback improves control. Every office needs a home blood-pressure-measurement program, and every patient in whom you are tracking blood pressure needs to measure at home. Check out the aforementioned websites for valuable tools, whether you are a provider or a patient!

Our sedentary lifestyles combined with our sugar-laden eating habits spells disaster for our waistlines and our blood-pressure numbers. Researchers are in the process of identifying “weight sensitivity” genes that will determine those who benefit most from weight reduction, but in the meantime abundant data shows that even 30 minutes of brisk walking five times per week will improve control of blood pressure—even in resistant hypertensives—and that obesity is responsible for about 60 percent of the increase in high-blood-pressure rates in this country over the last 15 years.

Sleep—that is, not getting enough of it—sabotages both weight loss and blood-pressure control. Sleeping fewer than six hours per night is associated with weight gain, stroke and other cardiovascular events, even in the absence of known hypertension. Thirty percent of working adults get fewer than six hours of sleep per night. Sleep-disordered breathing also contributes to uncontrolled high blood pressure, stroke and atrial fibrillation. Screening for sleep disorders and insufficiency using tools such as the Epworth Sleepiness Scale takes about one minute.

The Dietary Approaches to Stop Hypertension (DASH) diet is more than a flash in the pan! Adherence to DASH (eating four or five servings of fruits and vegetables daily, whole grains, low-fat dairy, limited sweets and moderate meat and sodium) is associated with improved blood-pressure control and decreased risk of recurrent kidney stones. DASH is being studied in patients with CKD for improvement of acidosis, blood-pressure control and CKD progression.

What about updates on evaluation and treatment of hypertension?

Control levels have been simplified: Most patients, including diabetics, need a blood pressure of less than 140/90 when taken in a doctor’s office. Exceptions include the elderly (people >80 years of age, whose goal is 150 mmHg systolic in-office) and individuals with more than 1 gram of protein in the urine over 24 hours, or a history of stroke (for these groups, lower blood pressure is indicated—less than 130/80 mmHg in-clinic).

Medication administration: Taking at least one BP med at night improves outcomes in middle-aged hypertensives, including diabetics MAPEC study1; and a combination of ACE inhibitors and calcium-channel blockers (ACEI/CCB) is superior to ACE inhibitors and hydrochlorothiazide (ACEI/HCTZ) ACCOMPLISH2. Control rates improve with the initial use of combination medications, even in Stage 1 hypertension.

Resistant hypertension: Use of 24-hour ambulatory blood-pressure monitoring (ABPM) shows that up to one-third of those who exhibit resistant hypertension in-office have controlled blood pressure out-of-office. This available technology is woefully underused, in part due to resistance from insurers. ABPM also identifies patients with “white coat” hypertension (higher in-office than out-of-office measurements, associated with moderate increased cardiovascular risk) and masked hypertension (BP higher out-of-office than in-office, which means increased risk for the patient and is an area of intensive current study). For individuals with true treatment-resistant hypertension, a thorough search for secondary causes is indicated; if none are found, renal denervation offers promise as an additional tool to improve control.

I hope you will join me in celebrating National High Blood Pressure Education Month by improving your blood pressure and that of those around you!

By Susan Steigerwalt
Susan Steigerwalt, MD, FACP, is director of the Resistant Hypertension Clinic at St. Claire Specialty Physicians, P.C., and at the Providence Hospital Heart Institute. She’s a practicing nephrologist and is also a site principal investigator for the Symplicity trial of renal catheter denervation in resistant hypertension.

 

References

  1. Hermida, et al. Chronobiology International 2010. September 27(8): 1629-1651
  2. Jamerson K et al : NEJM 2008 (359): 2417-2428


 

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May 15, 2013

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By Robert Provenzano, MD

DaVita Hospital ServicesSM is the first and only Joint Commission-accredited provider of inpatient kidney care and apheresis therapies. DaVita’s Ambulatory Health Care Accreditation* signifies a formally outlined set of standards by which quality and patient safety related to inpatient kidney care will be monitored and evaluated in the future. In this one-minute video, I discusses the benefits of this selective distinction for our patients and physician and hospital partners.

*Accreditation was based on a survey of 177 DaVita acute programs, which included Joint Commission accredited hospitals and other hospitals permitting The Joint Commission access for purposes of the survey process (a limited number of hospitals did not permit access).

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April 29, 2013

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By Robert Provenzano, MD

As a mentor for nephrology fellows, I frequently share my advice with young nephrologists beginning their careers. In this three-minute video, I pose the question “What’s the most important thing in medicine?” The answer should be “having fun.” Nephrology can be a challenging practice, so it’s crucial to truly love what you do and explore the opportunities that make sense for you. Take a moment and think about how you can find your professional passion in a rapidly evolving healthcare environment.

How are you trying to find the niche that works for you?

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3 votes, 2.33 avg. rating (57% score)
 
April 2, 2013

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By Robert Provenzano, MD

Benjamin Solomon Carson Sr. is an American success story. Dr. Carson was born in my hometown of Detroit, Mich. He was raised by a single mother and struggled academically throughout grade school. His mother reduced his TV time and required him to read two books per week, and produce written reviews for her. Little did he know that she herself could not read his reports. He began to excel in high school, graduated and attended Yale University, where he earned a degree in psychology. He then attended the University of Michigan Medical School and went on to subspecialize in pediatric neurosurgery. (He recently stepped down as the director of pediatric neurosurgery at Johns Hopkins Medical Center.) In addition to this, he was awarded the highest civilian honor in the United States, the Presidential Medal of Freedom, by President George W. Bush. Dr. Carson is a no-nonsense man; he is not an apologist. He was guided by a strong mother who always drove him to look forward, no excuses. He is revered in Detroit as someone who “made it.”

Recently Dr. Carson spoke at the 61st Annual National Prayer Breakfast(1) with President Barack Obama and Vice President Joe Biden in attendance. Dr. Carson spoke plainly about the “moral decay and fiscal irresponsibility” facing America today. Not caring whether he was politically correct or not, he stated that “PC is dangerous. . . . In this country, one of the founding principles was freedom of thought and freedom of expression. [Political correctness] puts a muzzle on people.” How true. Dr. Carson went on to offer his well-thought-out views on a solution for healthcare in the United States.

His solution? “When a person is born, give them a birth certificate, an electronic medical record, and a health-savings account [HSA] in which money can be contributed, pretax, from the time you’re born until the time you die. If you die, you can pass it on to your family members and there’s no one talking about death panels. We can make contributions for people who are indigent. Instead of sending all this money to some bureaucracy, let’s put it in their HSAs. Now they have some control over their own healthcare. Very quickly they’re going to learn how to be responsible.”
Currently Medicare funding is based on a 1970s rule allowing “baseline budgeting,” a guaranteed increase of the Medicare budget year over year. Any “cut” is a reduction of this guaranteed increase. Imagine if your salary since the 1970s had a guaranteed 5 to 10 percent increase year over year! This has created wasteful spending, inefficiencies and deficits. Compound this guaranteed yearly increase with the reality of continued cutbacks that affect the end users; i.e., hospitals, physicians and beneficiaries (patients). Where does the difference between the increase and the cuts go? Into an out-of-control bureaucracy. This is unacceptable and, sadly, rarely focused on in the media.

Dr. Carson offered a clear, simple, honest and elegant solution. How were his comments and suggestions received? In a recent interview Dr. Carson stated, ““There were some [responses] from individuals who were relatively narrow-minded and sort of like to put people in categories and boxes and can’t understand why you would move off the reservation”(2); this is sad. Great thinkers, great humanitarians, great men like Dr. Carson deserve the respect, admiration and support of good people.

Dr. Carson has embarked on a nationwide tour to reach out to communities, support education and be heard. If you have the opportunity to attend one of his presentations, I encourage you to do so. Support him.

Let your Congresspeople know that you believe there are solutions that don’t emanate from Washington, D.C. Get involved, be heard and be active.

1. http://www.youtube.com/watch?v=KpiryahOspY
2. http://www.newsmax.com/Newsfront/Carson-Prayer-Breakfast-Speech/2013/03/19/id/495263

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March 22, 2013

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By Robert Provenzano, MD

End of life discussions are always a sensitive and difficult subject to discuss with elderly dialysis patients. Today, I want to talk about why end of life planning should not be looked at as a broad decision based on chronological age, but rather a one-on-one opportunity to ensure the highest quality of life on a per patient basis.

How are you approaching end of life planning with your dialysis patients and what advice do you have for other physicians?

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4 votes, 4.75 avg. rating (94% score)
 
March 7, 2013

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By Robert Provenzano, MD

Those of you who didn’t attend the American Society of Nephrology meeting this past October missed an opportunity to enjoy a provocative lecture given by Bruce Vladeck, PhD, a former administrator at Health Care Finance Administration (HCFA). He spoke at the Christopher R. Blagg Endowed Lectureship in Renal Disease and Public Policy, cosponsored by the Renal Physicians Association. Dr. Vladeck touched on many issues that were highlighted at Kidney Week’s public-policy sessions throughout the meeting. Specifically, he focused on the allocation issues known to all of us concerning dialysis patients today. He provided data suggesting that social-economic status is often used to ration ESRD care in our country. He stressed what we have come to know: that focusing on coordinated, comprehensive and integrated primary care could help reduce these costs, but often this care is not available to the sickest or poorest people who need it first. In addition, Dr. Vladeck correctly focused on end-of-life conversations often ignored by nephrology care-givers and admitted that this is certainly one of the heated debates that quickly devolve into talk of “death panels.” Recent data suggests that frail, elderly patients do as well, if not better, with conservative CKD stage 5 management; making increased focus on end-of-life options a compelling argument.

Don’t get me wrong—I am 100% behind broadening the primary-care support for patients with CKD, particularly among those in underserved areas. But currently there is not only no incentive but often a disincentive for physicians to practice in those areas, and the barriers must be taken down before we can make meaningful reform in these areas. Additionally, I am 100% in favor of quality-focused, often-difficult end-of-life discussions with families and patients of the elderly who may indeed do better without dialytic therapies. But again, these conversations that take time and skill are currently far more challenging than preparing somebody for dialysis.

Indeed, if one steps back and looks at what our politicians would have us believe is appropriate reform due to the often-quoted “unsustainability of healthcare costs in this country,” I am onboard in total. As a healthcare provider I can see that reform is necessary. I can see that there is ample waste and there are more-efficient ways of providing care with a better value proposition. I do think that we can lead in healthcare. I think physicians can lead, hospitals can lead, and commercial payers can lead. Indeed, I think despite the obvious hiccups that a reinvention of processes of care will require, in the long term patients will be better off. But if the basic premise of unsustainability, patient accountability, the time for modernizing healthcare, is true, shouldn’t we step back and look at all of our entitlement programs? Why is this true only of healthcare? Isn’t it true of every other aspect of entitlement care in this country? Can you truly isolate accountability in one aspect of our society and not others? I am all for entitlement reform and accountability in healthcare, and yes, every other program currently offered to each of us.

As always, let me know your thoughts!

Merry Christmas and Happy Hanukkah
Robert Provenzano, MD
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2 votes, 4.50 avg. rating (90% score)
 
December 20, 2012

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By Robert Provenzano, MD

In this short, two minute video, Robert Provenzano, MD, discusses the perceived shortage of nephrologists and his thoughts on nephrologists’ professional role in the changing healthcare landscape. Hear his views on the future of nephrology.

Robert Provenzano, MD
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4 votes, 4.75 avg. rating (94% score)
 
December 6, 2012

One Response to Preparing for the Future of Nephrology

  1. Ken Boren says:
    December 13, 2012 at 7:15 pm

    This is a most important concept that all Nephrologist need to understand. We can not continue to use the systems of managing patients that we all grew up with. The future will be with the use of teams of nephrologist who will manage NP and PA to drive heath outcome. The will happen. It will be driven for insurance companies or Hospitals if we as Nephrologist really don’t step up an change how we manage patients. In This system we will be manageing non nephrology systems such as diabetes with a occation endocrinologist who will only help on difficult case or cardiologist who will be involved with simular patient. The world will center arround who will be able to accomplish this transition. It really need to start wilth our medical education systems but we as establish practioniers need to addopt this changes or some one else will do it for us and we will be left out of controll.

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By Robert Provenzano, MD

When I graduated from my fellowship in 1988, Nathan Levin, my chief, pulled me aside to congratulate me. I told him in confidence that I was still unsure of my clinical knowledge and experience and asked if it would be OK if I occasionally reached out to him with questions about complicated cases. He assured me that he would always be available to me and that over time my experience and confidence would grow. He was right on both counts. I found that I rarely had to bother him, and over the ensuing few years post-graduation I felt more comfortable with the majority of clinical cases I confronted. I continued this tradition of mentoring graduating fellows, as many department chairs do, and I suspect the graduates all found what I did: that the security blanket, although there, was needed only for a few short months, after which they were able to fend for themselves.

Jump forward 20 years; there has been an explosion of evidence-based medicine, and new processes, procedures, patient expectations, and on and on, making the ability for any one of us to remain at the top of his or her game much more challenging. Enter NephLink™!

What a godsend—a web-based portal that allows all nephrologists, any nephrologist, to communicate with their peers, their past fellows, colleagues with whom they’ve trained, local nephrologists or nephrologists anywhere in the world about questions or concerns on every conceivable topic in nephrology. This is nephrology of the 21st century! It’s a way of “spell-checking” your decisions—your clinical expertise—with trusted colleagues.

To be honest, it seems to me that this is not a luxury, but a necessity in our clinical practices!

I would encourage my colleagues to check out this website and review the ongoing conversations, debates and/or questions that have been posed. It’s worth a look, it’s worth a try, and it’s time to enter the 21st century.

Robert Provenzano, MD
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Introducing NephLink: The Online Physician Community for Kidney Care

Introducing NephLink –the new online physician community for kidney patient care. NephLink is designed to allow physicians (nephrologists, surgeons, internists, etc.) to discuss difficult patient cases or practice management issues, share best practices and ideas, and debate the evolving healthcare landscape, at no cost. NephLink provides physicians direct access to their colleagues to engage and collaborate as a group, or one-on-one, with self-service privacy controls. www.NephLink.com

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4 votes, 4.50 avg. rating (90% score)
 
December 6, 2012

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By Robert Provenzano, MD

Yep, you guessed it; this is one of many famous quotes from The Wonderful Wizard of Oz. We’ve all seen the movie, based on the book published in 1900 by L. Frank Baum. What, you may ask, does this story have to do with healthcare? Let’s see. My interest in this story was reignited by a recent article in The Pharos the Alpha Omega Alpha medical honor society’s magazine. The story focused on L. Frank Baum’s congenital heart disease and how as a frail child he turned to telling tales as a way to entertain his friends, and later in life, his children. He lived in Chittenango, a small town in upstate New York. The roads were made of wood planks and had to be constantly repaired by local “tin woodsmen,” the basis of the tin man. Baum was sent away at age 12 to a military academy to help shape him into a man. He failed there, either because of his weak heart or for reasons not described. The story describes how he left town dejected, traveling the main street of the academy, which was paved in yellow bricks.

Mr. Baum brilliantly wove his early life experiences into a wonderful tale that speaks to each of us. Today’s blog title speaks to me; speaks about the anxieties we physicians feel about the current healthcare environment. Yes, “lions and tigers and bears! Oh my!” Is there truly something to be feared? In The Wonderful Wizard of Oz it turned out that indeed there was not, that the characters’ fears were misplaced. That following your heart, following the yellow-brick road took them all where they could find happiness, fulfillment. So what is our yellow-brick road? What do we need to do? What are our responsibilities?

Healthcare, as an entity, can be viewed much like the wood-plank road in need of constant repair. One could argue that needed “repairs” to healthcare have been neglected for a long time and despite the continued improvements in technology and operational aspects of medicine, fragmentation and poorly coordinated processes have worsened and resulted in poor patient value. Could our yellow-brick road be the path we could be following to deliver to our patients a transparent, safe, efficient, predictable care product? If it is, then are the threats and barriers, (and some monsters) we find along this path real? Fears of loss of economic viability, loss of control, loss of professional identity must be dealt with. Yet down this road we move; we must. We have a long way to go to reach Oz!

There are still many options available for all physicians, but particularly for nephrologists. I have mentioned some before but think them worth repeating. First, joining a hospital is an option; it is probably the least desirable. Nephrology is quickly diluted among high revenue generators—think cardiology and oncology. We would suffer from lack of fair and appropriate revenue distribution since we are cost containers, not so much revenue generators! Second, continued consolidation of practices, both locally and regionally, offers increased security; greater independence; broader investment opportunities; more leverage in payer contracting and, finally, broader, mature partnerships with dialysis organizations—a unique relationship that has existed for years. Lastly, a third, as-yet-untried model is to partner with (working for) a dialysis organization. That would bring total clinical alignment, with the financial relationship as yet undefined.

We are all traveling down the yellow-brick road. We are on this journey together, and can we see Oz? Some can, some cannot.

Educate yourself, continue to move down the path, down the yellow-brick road. DaVita is prepared to work with our nephrologists to assist in obtaining satisfaction in practice, delivering clinically relevant superior outcomes and creating a stable and predictable financial environment for our physicians’ teammates.

“Toto, I don’t think we’re in Kansas anymore!”

—Dorothy

Robert Provenzano, MD
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2 votes, 4.50 avg. rating (90% score)
 
September 27, 2012

One Response to “Lions and Tigers and Bears! Oh My!”

  1. Francis zambetti says:
    September 29, 2012 at 6:09 pm

    Very timely. One should explore all options including hospital, area HMOs – many of them are subsidiaries of ACO’s, and of course DaVita. Each may have unique options to bring to the table, and more importantly limitations especially when it comes to each States law concerning acquisitions. If you know who your ACO is going to be, this is the time to meet before someone else decides you place or lack of. Or It is time to get the HELL out of Dodge if you can!

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By Robert Provenzano, MD

As is tradition in our hospital training program, I had the pleasure of speaking to the new interns, medicine residents and nephrology fellows for the incoming class in July 2012.

As you know, their first few days of training are spent with “hospital indoctrination,” where trainees are bombarded with passwords, pass keys, phone numbers and extensions, IT education, policies and procedures, the call-rooms locations, and on, and on and on. When I finally had my chance to address them they looked tired, bewildered and glassy-eyed. What was a division chief of nephrology going to say that would make any difference to wide-eyed, frightened new doctors?

I decided to ask them, as I do each year, two questions that have increasing relevance in today’s world. These questions have yet to be answered correctly by anyone in the audience, in over 20 years. Although their lack of a correct answer could be due to fear or fatigue, I believe it is due to a true lack of understanding of what is important in their professional lives. So what were these questions? Here they are:

1. What is the most important thing for them to experience in medicine?
Answer: Having fun.

2. What is the hardest thing in all of medicine to do?
Answer: Doing nothing.

As we enter an age in which integrated care puts increased pressure on physicians specifically and the healthcare system in general and where doing the right procedure for the right patient at the right time has increased focus, these two questions have become more relevant.

Let me explain:

Question 1: physicians have a gift. You can consider it God-given or otherwise, but it is a gift—a gift to be able to walk into a complete stranger’s room and have them lay before you everything they are about. Our gift is no different than the gift a musician or an artist may have, creating music or art out of nothing. Residency and fellowship training programs are where doctors hone their gift, hone their respect for patients; where they listen and learn. If the don’t understand that they have a gift and that this gift exists for their patients and their communities and not for themselves, then they will never be happy and they will never have fun. I contend that they should wake up every day with the passion and excitement to be able to use the gift they have, the gift that continues to grow: to care for patients and be a part of the healthcare system where they are being trained as leaders. If they lose their passion, if any of us lose the ability to have fun, what are we, after all? Just unhappy practitioners passively floating in the sea of change that flows all around us.

Question 2: why is doing nothing so hard? It’s hard because it takes time, and time is one of the most valuable commodities a doctor has. Patients expect you to do “something.” If you’re going to do nothing it seems like the world turns against you. We’re under pressure for keeping length of stay low. We’re pressure from a senior resident, an attending or someone else to do something. But as we all know, that something has costs both financial and clinical. You can certainly easily justify why you didn’t order the fourth CAT scan of the hospital stay or an EEG whose results do not add to the knowledge of the case. By explaining why your clinical observations justify waiting and watching, sometimes in an outpatient relationship, rather than being a “protocol physician” who pumps out test after test that adds little to care except risk to the patients; doing nothing is hard. It’s a skill. It’s sitting down with the patient and taking a few extra minutes to explain why holding off on a test is more prudent than moving forward with it. It’s the time you spend helping an elderly patient better understand why just because something can be done doesnt mean it should be done.

Come to think of it, these two questions help me better understand many aspects of today’s healthcare focus. I can only hope that as class after class of interns, residents and fellows pass through our institution we will build on the idea of finding a necessary balance between channeling their passion and the ability to do the right thing at the right time for their patients.

“If your actions inspire others to dream more, learn more, do more, and become more, you are a leader.”
—John Quincy Adams

Robert Provenzano, MD
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2 votes, 4.50 avg. rating (90% score)
 
September 21, 2012

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