Transcript:

Welcome to Kidney Health Connections, a podcast exploring the future of kidney health and the rapid shift to value-based care, where you can learn about the latest innovations that are helping patients live healthier, more fulfilling lives. Here's your host, Dr. George Hart.

Dr. George Hart: Hello, everyone. All of us do better when we're informed and understand the problem at hand. Same goes in healthcare, and especially kidney care, where we have such a complicated, severe disease, which in many cases has gone undetected. Much to learn and do, and what is sometimes not a lot of time in which to do it.

We nephrologists know this, but honestly, in a fee-for-service world, the resources, including provider time, are in short order. Effective education requires more time than we're able to spend with patients during a typical visit. It also requires meeting patients where they are; delivering the right message, to the right patient, at the right time.

In this episode of Kidney Health Connections, we speak with Dr. Marc Brazie, a nephrologist at Metropolitan Nephrology Associates in Northern Virginia, on the strategies and new tools available to support patient education.

Marc, thanks for joining, and welcome to our episode.

Dr. Marc Brazie: Thank you.

Dr. George Hart: We’ve got a lot to cover today. Really anxious to hear your thoughts on education for patients, because I know that's a bit of a passion for you. But first and foremost, though, tell us a little bit about your journey into nephrology and your practice there in the DC area.

Dr. Marc Brazie: Sure. So I kind of learned I was interested in nephrology in medical school. I just fell in love with renal physiology early on and knew pretty immediately that's what I wanted to do. And then it was just a matter of kind of confirming that through trying it out a little bit as a medical student and ultimately as a resident. I went straight into practice out of fellowship, and I've been with my practice my whole career. We're kind of a medium-sized practice in the southern DC metro area. We have an office in Alexandria, Virginia, and one in Clinton, Maryland, and we are seven physicians, three extenders, so ten providers total.

We are a pretty good mix. I mean, we see a variety of chronic kidney disease, end stage kidney disease. We have a pretty thriving transplant population. We follow about 350 to 400 kidney transplant recipients and kind of see the full gamut of things there.

Dr. George Hart: And you have to deal with DC traffic.

Dr. Marc Brazie: Indeed.

Dr. George Hart: Tell me a little bit about your typical day, going to more than one location, how much windshield time do you have? Give this audience a picture of, you know, what a day is like.

Dr. Marc Brazie: We're a little unusual in that sense. I think we're scheduled and structured differently than your average nephrology practice. We try to only go to one location any given day.

So we have several different offices. We have a few different hospitals in the DC area that we cover. We have six or seven different dialysis facilities that we cover, but we try to assign things where if you're doing dialysis rounds, that's what you're doing for that day or two, and you just camp out at that clinic and see all, you know, 40 or 50 patients that might be coming through that day and don't have to drive back and forth. If you're in the office that day, you're in the office for the entire day. If you're covering the hospital, we do that for a week at a time, you're just the hospital doc for the week.

And so it minimizes a little bit of that driving between locations within the day, although on any given week, you know, where you're practicing out of changes from week to week, and day to day within the week.

Dr. George Hart: But still a very busy day.

Dr. Marc Brazie: It's a busy day, and they can be long days for sure. Right.

Dr. George Hart: So I'm going to take you back in time for a second. Let's go back five or ten years, pretty much wholly in a fee-for-service environment. Tell me about, I mean, were you able to do much kidney disease education then?

Dr. Marc Brazie: When I first joined, we really didn't have a particularly structured kidney disease education approach at all. And we recognized probably five to ten years ago, somewhere in that window, that we really needed something, that we needed to do a better job. I actually believe in the first five years or so I was with my practice that I only recall seeing one or two dialysis patients start dialysis with a mature vascular access. And we did a very poor job of preparing our patients.

And so we created our own internal education program initially, that one of our APPs put together, that was an hour-long education session that they ran. And they created a PowerPoint slide deck, and they would walk through that slide deck with the patients and go through various aspects of the kidney disease education, transplant, and various dialysis modalities, touching a little bit on conservative kidney care as well in there.

But it was really just this one-hour massive information dump that, to be honest, I think many patients felt overwhelmed by because we were trying to do it all at once. And it was very hard to schedule because it required an hour of provider time. So we had to really carve out time on the APP schedule to reserve for these education appointments that we would not fill with any other types of follow-up appointments to make sure that we could preserve an hour block like that for this education.

Dr. George Hart: So you mentioned patients being overwhelmed, and in my career, I saw a lot of that as well. It's a lot of information to take in, particularly if you don't feel well, and if you're time rushed. Did you find that back five or ten years ago you saw patients later in their disease course than maybe today, or any differences in that regard?

Dr. Marc Brazie: I think that has changed a little bit. Earlier on, I do think that primary care providers would often refer patients a bit later in the disease process. They would often identify patients that had early chronic kidney disease, and I think that they were aware of it. But many primary care providers had the mindset of, well, you're not really close to needing dialysis at this point. We'll wait until you're more ill before we get the nephrologist involved. And we would often see patients that were already stage 4 or approaching stage 5 by the time that they were referred.

I do think that's changing, and that's changing for the better in the last three to five years. I am seeing many more patients now with earlier stages of chronic kidney disease, and I think that's certainly very appropriate in today's day, with some of the newer tools we have to get some of these patients upstream, where hopefully we have an opportunity to intervene and make a difference earlier in the disease process.

Dr. George Hart: One of the things that was such a shock to me when I jumped from private practice to where I sit today is learning that a staggering number of patients know nothing about their kidney disease despite being late stage. As many as 40 to 50 percent of stage 4 or stage 5 patients have never seen a nephrologist, don't know they have kidney disease, many of which don't have even a primary care doctor.

Maybe help us understand, or help this audience understand, what it's like to have to show up to see someone in the ER, they've had no preparation, and have to have this conversation about, “Hey, you have irreversible disease,” and we need to do something that they knew nothing about before now.

Dr. Marc Brazie: Yeah, it's a really hard situation, and it's an unfortunately still common scenario that you present there. I would say probably five to ten times a year, we're meeting a patient just like that that's coming into the hospital because they don't feel well, and they already have significant and advanced permanent chronic kidney disease. And it's a tragedy because, most of us know this, but at least early in the course of kidney disease, there really are no symptoms. So there's no way for patients to know based on how they feel how their kidneys are doing, or that they have kidney disease.

A natural tendency of healthcare providers is, we often don't like to talk about challenging and difficult things with patients, so we use slightly flowery language, or we use evasive language. So they maybe have even been seeing their primary care doctor every year for years, and their primary care doctor is aware of the fact that they have chronic kidney disease, but they've never expressed that to the patient in those concrete terms. They'll say, “Oh, your kidney levels are a little bit off, and we'll keep an eye on it.” But they don't really say the words “chronic kidney disease.” They don't really discuss what that means. They don't define that for the patient. They don't give them any insight into where their kidney function truly stands.

And so even though they're referred to me with something that, in my estimation, their primary care doctor has known about for years, they're really coming to us oftentimes with absolutely no idea what's going on. They often don't even know exactly why they've been referred. Other than that, the doctor said, “I'm a little bit worried about some of your numbers, and I want you to see the nephrologist.”

Dr. George Hart: Well, that could be a little awkward, I think, when you walk in and have that sort of expectation on a patient's part, or maybe the lack of. But what you really kind of allude to as you're talking and describing all of this is, you need time. You need time with a patient, time to build rapport, familiarity. How do you start? When do you know you have time to talk about the basics of CKD, dietary, you know, interventions versus you're in a little bit more of a rush?

Dr. Marc Brazie: It depends a lot on, obviously, when we're meeting the patient and where they are in that chronic kidney disease journey at the time that they meet us.

If someone is being referred to me late, you know where they're already in stage 4 chronic kidney disease, particularly if I have historical labs showing that this is something that's been progressing, then I can anticipate that their risk of kidney failure in the next two years or the next five years is fairly high. Sometimes we have to jump more directly to transplant education and dialysis options education and skip some of the preliminary things.

When I have the opportunity, when someone is referred to me earlier, that gives us the luxury of spending a bit more time talking about chronic kidney disease in more general terms — how we measure it, how we stage it, what things cause it, what the interventions are that we know help to halt progression, or at a minimum slow progression, and talk more about those holistic, you know, how do we approach this in a more patient centered and holistic way? And then only if, despite those efforts, we're seeing ongoing progression, then we introduce some of those later concepts of preparing for renal replacement therapy. But it's much better when we have that second scenario.

Dr. George Hart: Totally agree. I was in a large practice for 30 years down in North Carolina, and 45 physicians, about 40 advanced practitioners. You mentioned kind of this hesitancy or aversion to having the hard conversations. I certainly saw that with some of my partners, not everybody was created the same. I did see an advantage with advanced practitioners who seem to be maybe sometimes better able to establish a connection, and we utilized advanced practitioners in our CKD protocol. Similar experience for you?

Dr. Marc Brazie: Yeah, I think we've had a very similar experience to that. In the education realm in particular, that's a very natural fit for advanced practitioner providers. It tends to be a skillset that they are good at in terms of how they relate to patients, in terms of that education and breaking things down and explaining things to them, and I think it's a very good use of their time.

A lot of practices also structure their schedule in a way where much of the dialysis care is provided by advanced practitioners as well. And therefore truly within our practice, I believe that those providers are the experts on dialysis care in our practice. And so not only are they naturally good educators, but they know a lot about dialysis, and therefore, are really able to answer a lot of deeper questions when patients have them.

Dr. George Hart: You have a chance to meet with a patient, you know they're coming in for an education visit, what are some of the tools and resources that you find helpful as you take the time to walk through this with patients?

Dr. Marc Brazie: I think you have to have some kind of a structure to your education program. It certainly can't be that you just schedule an education visit and that you have whoever happens to be meeting with them that day do it off the cuff.

We happen to be now using the Interwell Learning platform for our chronic kidney disease education. That is a great tool, and I'll tell you, some of the things that I like about it are that it is structured in a way where it's broken down into more bite-size and manageable pieces for patients. There are six different workshops, and the early workshops talk about kind of general chronic kidney disease management, dietary changes and things you can do to slow kidney disease, and then there are separate workshops on kidney transplant, on dialysis options, on conservative care without dialysis, and even kind of living well and coping with kidney disease and what does it mean for someone who's facing the prospect of starting dialysis imminently.

And it has helped us get away from some of the problems that we had in the past, in that our old education program was overwhelming to try to cover everything in one one-hour session, and that patients generally left kind of not really understanding any of it. And we spent the next several office visits having follow up conversations about things that they only kind of barely understood the first go round.

By breaking it down into smaller pieces, it gives you a chance to talk about each of those individually a bit better. It's also structured in a way where there's a video that's about 20-minutes long that's meant to be paired then with a 20- to 30-minute follow-up visit with the provider afterwards. So from a scheduling standpoint, these can be scheduled in any available follow-up slot with any provider, so it doesn't require having to completely restructure the office schedule to fit in education. And it's made it that we can make these appointments much more widely available to patients, which I think is good.

And the thing I like about it is, again, that there's a piece that focuses on that upstream chronic kidney disease education and interventions we can do to help manage kidney disease. It doesn't launch right into the dialysis conversation. You can gain a lot more trust and a lot more buy in from patients when the first words out of your mouth are not, “let's talk about dialysis,” which most of them don't want to talk about.

It's a good tool. I don't think it's essential, but I think people need a tool like that, whatever that tool is going to be. They need a tool because if you don't have some structure to how you're going to approach this, then it's not going to be consistent and you're not going to be able to be providing the right information at the right step of that patient's journey.

And the other tools are really the people, human resources part of it, is how are you going to free up time for this? And I think we touched on one part of it, which is using APPs to provide a lot of education. For many practices that would work very well, but I don't think this even has to be a fully licensed practitioner. I mean, you could use nurses, you could use RNs or LPNs to help provide this education. If you have a renal care coordinator or someone in a role like that within your organization, this is certainly an area that they do very well. I know many dialysis organizations also have educators that can meet with patients to provide education.

So there are a lot of different ways to approach this. I just think it takes having a plan and being committed to that plan and devoting the necessary resources to make sure that you really can offer this to every patient that needs it.

Dr. George Hart: You mentioned the renal care coordinator. Most of the time, that's a nurse who has quite a bit of experience with dialysis and CKD. You guys work with renal care coordinators. Elaborate a little bit more on what that experience has been.

Dr. Marc Brazie: Yeah, I think that has probably been the single greatest thing that has helped us as we have tried to journey further into value-based care. I think a very typical story for our patients prior to that is that we would meet with them, we would see that they have advancing chronic kidney disease, we would recommend that they schedule an education appointment, and then they would walk out to the checkout desk to check out, and they would say, “I'm not really sure when I can do that. I'll call you back later to schedule that.” And it just wouldn't happen.

Or we've even done education already, they've settled on in-center hemodialysis as their preferred dialysis modality, and now their GFR is 18 and I'm recommending that they go to meet with a vascular surgeon to get vein mapping done and begin the process of having a permanent access created and they, for lack of a better term, drag their feet a little bit about that and opt not to do that. And I think that's very common. I mean, it is human nature to be in shock and to have a little bit of denial when you are facing the prospect of something like starting dialysis, and it's very natural for a patient to not want to think about that more than they have to, and not want to think about that more than we make them think about it. And very easy for them to just put their head in the sand and wait till the next visit in the hopes that their numbers look a little bit better the next time.

And we at least were never good at tracking any of these things. And so having the renal care coordinators has been huge, because it's somebody who can track these patients with us, someone that they trust, someone that they build a relationship with, someone who, every time I see them, they look at my note and they say, “OK, this is what Marc wants them to do between now and the next time he sees them in six weeks.” And they're going to check in with them and they're going to make sure that these things are getting done and so much less is slipping through the cracks now.

And it's a really positive experience for me, because it's something I don't have to track and I'm not having to worry about. And it's a much more positive experience for the patients because they're having somebody who cares about them, who is reaching out to them to provide a safety net and to make sure that what really should be happening is happening. And somebody, again, they have built a relationship with, that they trust, and they know they can reach out to with questions and that when they call, they're going to take those calls and they're going to listen to what they have to say.

Dr. George Hart: It's good for me to hear that the similar experience for you and having patients fall through the cracks, it wasn't just me. Because I saw it a lot during my career and, you know, unfortunately for me anyway, and my patients, is that I spent most of my career, or much of my career, in a fee-for-service world.

But what you're really talking about is care navigation and creating a safety net, a mom or a parent, if you will, to kind of follow up behind the patient and make sure that the care plan that you put together actually gets executed, which is, again, I think we talk a lot about education, but you can't leave off this care navigation piece, too, to follow through.

Dr. Marc Brazie: No. And they dovetail very nicely together, because the education piece often leads to several actionable steps or actionable items on the patients, and that can then very naturally be followed up upon by the renal care coordinator. So the two really are kind of two facets of what leads to the optimum patient experience, assuming this is a patient that is ultimately approaching the point of kidney failure and the point of requiring some kind of support, being able to provide education and these care navigation resources, both, that's kind of the magic combination that really helps to support them through that journey from beginning to end.

Dr. George Hart: Marrying all that together is kind of the secret sauce. The other thing I found, you know, I think we physicians sometimes default to language that's unfamiliar for patients, and the renal care coordinators, some of our nurse practitioners, maybe speak in a language that's a little more understandable.

Dr. Marc Brazie: I think that's true. Some of it is that they're better able to relate to the patient and better able to explain things to the patient.

Sometimes, I think, too, just the repetition of hearing the same thing over and over again from more than one individual helps. The very first time new information is presented to a patient, again, some of it may be shock, some of it may be denial, some of it may just be that it's hard to wrap your head around new information the first time that you hear it. But then when somebody calls you a week later to check on you and say, “Do you have any other questions that have come up in the last week?” It gives them an opportunity to clarify that, to ask clarifying questions, to understand it deeper, someone else to explain it in a slightly different way, and then you start seeing everything click into place a little bit more.

Dr. George Hart: Couple of things I want to go over before, you know, we get too far down the road here. I have heard you speak about SGLT2 inhibitors, and the promise and the hope that they bring to slowing down the progression of kidney disease, whether it be old medications such as ACE inhibitors, angiotensin receptor blockers, or even SGLT2s, there's underutilization. How do we improve that? What are the steps that you're taking within your practice, with your partners, to help patients understand the value of these medications and making sure that more actually get a chance to take them?

Dr. Marc Brazie: Yeah, that's the key for the future of nephrology care, right, is how can we further slow the progression of chronic kidney disease, and how can we prevent patients from ever landing on dialysis in the first place? We are living through a revolution in nephrology, I truly believe this, with the discovery of the effects of SGLT2 inhibitors, and now more recently with GLP-1 receptor agonists and non-steroidal mineralocorticoid receptor antagonists, at least for diabetics, I think we are going to have the ability to, at a minimum, significantly delay progression for most individuals, and maybe even completely prevent the onset of ESRD for a significant number.

And the key is early education about kidney disease and early education about the benefits of these things, because we know that they all work by slowing the progression of the GFR slope, slowing how rapidly GFR is being lost. So if you don't initiate them until the GFR is 25, they're going to have much less of an impact than if you can start these interventions when the GFR is 45. So getting those patients early, and then providing that education early, so that we can start these therapies as soon as possible is the process that makes the hugest difference.

And one of the best tools that I found for this is the kidney failure risk equation. I think most people watching this probably know about this equation, but it's an equation that's come out in the last several years, looking at the variables that predict, what tends to predict, whether somebody goes on to develop progressive kidney disease and ultimately end stage renal disease or not, and then trying to stratify that, to calculate a two-year risk and a five-year risk for individuals.

And I've used this tool in various ways within my practice. I use it for patients who are very low risk to reassure them that they're low risk. I use it for patients who are approaching dialysis that are high risk to help drive home the need for preparation and advanced preparation for dialysis or transplant.

And I use it in this conversation, talking about things like SGLT2 inhibitor use. I go to the kidney failure risk website, and I show them how much their two-year risk and five-year risk can be reduced by adding an SGLT2 inhibitor. And when they see those numbers and they see that these medications nearly half the risk of kidney failure, that is often enough to get buy in, even though they may have reservations about taking something that's new, taking something that might give them side effects, things we're all worried about when we start a new medicine. But when I can show them how substantial the benefits are, I think it makes the risk seem more palatable to them.

Dr. George Hart: No doubt. I mean, I don't think any of us went into nephrology to care for patients on dialysis. I think we all would like to see us be able to keep patients off dialysis, improve their quality of life, the journey they have with kidney disease. And I think you bring up great points regarding the value of early education, care navigation, and then being able to put objective measures to some of these new technologies and therapies that are out there.

Marc, I can't thank you enough for coming today and speaking with us. For more patient education information and tools, please visit our website at interwellhealth.com. You can catch more conversations with experts in value-based kidney care by subscribing to Kidney Health Connections on the listing app of your choice. Thank you.

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