 Our next speaker is Dr. Mildes Saunders. Dr. Saunders is a hospitalist. There's this new kind of medical specialty at the University of Chicago and also serves as a clinical researcher and is also the living donor advocate physician at the University of Chicago Medical Center. Living donor advocates were something that we started perhaps as one of the national leaders in the late 1980s. Mildes' work focuses on racial disparities in quality of care and outcomes for patients with kidney disease. Mildes earned her M.D. from the University of Pennsylvania School of Medicine and a Master's of Public Health from Johns Hopkins School of Public Health. I'm sorry, Johns Hopkins School of Public Health. And today, Dr. Saunders will talk to us about bridging the knowledge gap, bridging knowledge gaps in patients with advanced chronic kidney disease. Mildes. Good morning. So today I'm going to talk about, so two treatments. So we have two treatments. Treatment A is associated with a 35% five-year survival. Patients are hospitalized on average 12 days per patient year and it costs roughly $90,000 a year. Treatment B is associated with improved survival of 45% five-year patient survival. Patients are hospitalized less at 11 days per year. Again, with decreased costs, $71,000 per year. And this treatment is associated with increased quality of life and lower stress scores. So then the question is, so which treatment would you choose for yourself and for your family? Okay, great. So I'm glad we all agree. I had to throw in the quality of life just in case there were a few people who thought this was a trick question. So in real life, in patients who actually choose treatments for treatment A, the one that nobody chose, 90% of patients with this disease are using treatment A and only 7% of patients with this disease are using treatment B. So if this were an immune modulator or chemotherapeutic agent, we would all be up in arms about the poor quality of care that we're giving to our patients and to the lack of dissemination for guideline-recommended care. This disease is end-stage renal disease. And these treatments are hemodialysis in which 90% of patients with end-stage renal disease start treatment with hemodialysis. And treatment B is peritoneal dialysis in which 7% of patients start treatment with peritoneal dialysis. Now, as you know, it doesn't add up. There's a small portion of patients who preemptively are transplanted and that's fantastic and we'd like to increase those numbers too because that's treatment C and it's even better than A or B. So this is important not only because it's a failure of patients to get the guideline-recommended care and care that we know can improve outcomes, but end-stage renal disease in the U.S. is high-cost. There are 600,000 patients with end-stage renal disease in the U.S. It's account for $47 billion in healthcare costs. It's also 7.5% of Medicare spending despite patients with end-stage renal disease being less than 2% of Medicare patients. And the cost is roughly $65,000 per patient per year. There's also a high cost to the patients with end-stage renal disease. There's high morbidity and mortality. Patients with end-stage renal disease have a hospitalization rate of about 1.9 per patient year and just to give you sort of a guideline. So in general, patients on Medicare have a hospitalization rate of about 1 third of that and a five-year survival rate of about 35%. So this is on par with some of the diseases that we sort of think of as the major scourges of our medical system including four of the five most common cancers. Yet we know that interventions that have been shown to reduce costs, reduce morbidity and mortality are underused. So AV fistulas, which we know is the merger of the vein and the artery for dialysis access, is associated with a 50% reduction in mortality and yet only 13% of patients start hemodialysis with a fistula. Our default for a variety of reasons is a catheter and patients are sent out to in-center hemodialysis where unfortunately many remain for the remainder of their dialysis course. Peritoneal dialysis is somewhat controversial for many people but it's associated with reduced cost and improved outcomes at least in the first five years. However, only a low proportion of patients choose peritoneal dialysis despite the fact that 75% of patients have no medical or social contraindications to peritoneal dialysis. In transplant, compared to all comers, we know that it reduces mortality and it also costs less. However, only 30% of prevalent patients with in-stage renal disease have been transplanted and additional 20% are on the wait list. So one challenge is that currently, despite mounting evidence that we have better options for our patients, there's no required process to inform patients of the risks, the benefits, or other options when starting renal replacement therapy. So patients who come in in extremis and meet criteria for beginning hemodialysis are given presumably informed consent for the placement of the dialysis catheter. That's it. There's no additional information given about the procedure and other choices that they could make to improve their outcomes or the risks that they take by going down this route. So there are multiple reasons for this. One is there's a challenge in identifying patients with advanced chronic kidney disease. So we know that many patients do not know that they have kidney disease. So our own work used the University of Chicago's hospitalist data set, which tracks hospitalized general internal medicine patients while they're hospitalized and post-discharge. And in this, one of the things that we asked was, tell us about your medical conditions. And so we looked at patient reports of kidney problems, not severity, just do you know that you have a problem with your kidneys. And we corresponded this to ICD-9 codes, which again, we know are under-reported. So 24% of patients with stage 3, which is moderate chronic kidney disease, reported that they had kidney problems. The numbers were higher, but still not where they should be. So about 61% of patients with stage 4 chronic kidney disease reported that they have kidney problems and 67% of patients with stage 5, which is advanced chronic kidney disease where we really are starting to think about renal replacement therapy, report that they have kidney problems. So unless you know you have kidney problems, even if your physician tells you you need to start thinking about dialysis or you need to go to a nephrologist, it's something that you just can't take seriously because it just hasn't made your list of things that you were worried about that day. However, we can't just say it's a patient problem. Physicians also don't know or correctly identify patients who have kidney disease. So in one study looking at older patients, physicians only correctly identified 40% of patients with chronic kidney disease, even though their GFR showed that they had kidney disease, only 46% of the time that physicians code this is a problem. In another study looking at patients with stage 5 kidney disease, so again, advanced chronic kidney disease where patients need now to be referred and start planning for renal replacement therapy in a Department of Defense study, only 65% of patients with the most severe chronic kidney disease have been referred to a physician, I mean to a nephrologist. There are also challenges with funding for advanced chronic kidney disease. So due to a quirk in our system, once you get in-stage renal disease, you are eligible to be covered for Medicare. However, prior to that, you're on your own. So we know that 6.2% of patients with advanced chronic kidney disease are uninsured at the time of dialysis initiation and an additional 11% have Medicaid only at dialysis initiation. And so this insurance, this under insurance or lack of insurance often leaves patients without a source of usual care or without access to a nephrologist. And this has important implications both in clinical care prior to the onset of in-stage renal disease but also in patient education and procedures to prepare. And we know that this is important because pre-renal replacement therapy patient education leads to better outcomes. Reduced central venous catheter use, improved uptake of self-care dialysis, which is peritoneal dialysis or home hemo dialysis. So things where patients are primarily responsible and have control over their treatments and also leads to increased access to transplant for patients with in-stage renal disease. However, despite this evidence, we know that only 43% of patients with in-stage renal disease had seen a nephrologist prior to dialysis initiation. So one bridge, one solution to this is the hospital. I'm a hospitalist, that's my disclosure so I think it's an important place. So we know that many patients with advanced chronic kidney disease, regardless of their insurance status, regardless of their knowledge, are hospitalized in three months prior to dialysis initiation. So we think the hospital is a missed opportunity to identify, educate and refer patients with advanced chronic kidney disease. So as part of my work and the research team, we are proposing to develop, test, implement and evaluate a patient referral and education program primarily for African American hospitalized patients with advanced chronic kidney disease in our own institution. Hoping that we can improve, reduce disparities and improve quality of care for patients within our hospital and ultimately serve as a model for other institutions. But there are other important things that happen outside of the hospital in addition to this. So one is simply what we have to do with a bunch of other issues. So talking early and often to our patients about chronic kidney disease to remind them that it's on their list with their diabetes and hypertension and heart disease and osteoarthritis and all the other things that are important to them or that they worry about. And to educate them and ourselves often about in-stage renal disease options. There's been work in other disease states with patient educators, peer patient educators or patient navigators that help patients to learn more about their disease process and to navigate the complicated system required to gain information and make choices about care. There's also work to be done for clinical pathways where we have computer alerts or automatic order sets for patients with advanced chronic kidney disease so that we can identify, refer and evaluate them. And then another option is unfortunately patients come to us in need of urgent renal replacement therapy. And so programs across the country are starting to do rapid start peritoneal dialysis. So patients still who have come in need of dialysis peritoneal dialysis as an option. There are also policy remedies that are exciting and that are underway. So healthcare reform, it's a topic of this year's McLean conference so I don't need to go into it. But we have expanded Medicaid and health insurance exchanges so that patients who need healthcare prior to the onset of their in-stage renal disease can get it both to prolong time to in-stage renal disease and also to have patient education for renal replacement therapy. As part of CMS policy, Medicare now pays for pre-in-stage renal disease education for patients with, for Medicare patients. So usually patients over 65 with advanced chronic kidney disease so stage four or greater. And additionally, in 2014 patients with AV fistulas will be a pay for performance measure for dialysis centers. If we aren't able to give them the education and access that they need, there will be an incentive for them to go back and pick up where we left off. And dialysis centers will be penalized if their number of patients with AV fistulas don't meet national standards. So in conclusion, in-stage renal disease is a high-stakes disease. So it's high cost to society and it's also a high cost to patients with morbidity and mortality and reduced quality of life. We know that there are several renal replacement therapy methods including hemodialysis with an AV fistula, peritoneal dialysis, and of course transplantation that have been proven to reduce these negative consequences. However, renal replacement choice is preference sensitive, but it requires individual practitioner, system, and policy changes and informed renal replacement therapy choices. We have time for a question or two. Dr. Solmezzi. It is not, actually. So there's recently been a change where CMS will now fund peritoneal and hemodialysis at the same rate. And since we know that peritoneal dialysis actually costs less, there should be an incentive for dialysis facilities to educate and to divert interested patients to peritoneal dialysis. But do you suggest it had been differentially paid in the past? So it had not been paid in the past. So this is a recent incentive and so we have to sort of get all of our other systems aligned to deal with that. Can I give you a setup question? Since B was better than A and B, a C being kidney transplant, why aren't we offering kidney transplants to everyone? Well, that is a plug for a living donation. So part of it is we just don't have enough kidneys for everyone and really given that this kidney transplantation or organs in general are a scarce resource, we need to figure out who would best benefit. But that being said, we can do things to decrease that scarcity since it is the best outcome. Milda, thank you so much. Thank you.