Renal Physicians Association Clinical Practice Guideline #3 Appropriate Patient Preparation for Renal Replacement Therapy Executive Summary October 2002 Duke Evidence-based Practice Center Center for Clinical Health Policy Research Renal Physicians Association Clinical Practice Guideline #3 Appropriate Patient Preparation for Renal Replacement Therapy Executive Summary October 2002 Duke Evidence-based Practice Center Center for Clinical Health Policy Research Appropriate Patient Preparation for Renal Replacement Therapy WORKING GROUP Patricia Painter, PhD University of California, San Francisco Renal Physicians Association San Francisco, CA W. Kline Bolton, MD, Michael Rocco, MD, MSCE Working Group Chair Wake Forest University School of Medicine University of Virginia School of Medicine Winston-Salem, NC Charlottesville, VA William F. Owen, Jr., MD Association Representatives President, RPA Carolyn Atkins, RN, BS, CCTC Duke University School of Medicine National Kidney Foundation Durham, NC Medical City Dallas Hospital Dallas, TX Baxter Healthcare Corp. McGaw Park, IL Shelley Clark, RN National Renal Administrators Association Dale Singer, MHA FMC North Roanoke Dialysis Executive Director, RPA Roanoke, VA Paul Eggers, PhD Content Experts National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Jack Coburn, MD Bethesda, MD UCLA School of Medicine West Los Angeles V.A. Healthcare Center Lori Fedje, RD, LD West Los Angeles, CA NKF Council on Renal Nutrition Pacific Northwest Renal Services William Haley, MD Portland, OR Mayo Clinic Jacksonville, FL Richard Goldman, MD Renal Physicians Association Annamaria Kausz, MD Renal Medicine Associates, Emeritus New England Medical Center Albuquerque, NM Boston, MA Joel Greer, PhD Adeera Levin, MD Centers for Medicare and Medicaid Services St. Paul’s Hospital Baltimore, MD Vancouver, BC Richard Lafayette, MD William Mitch, MD American Society of Nephrology University of Texas Medical Branch Stanford University School of Medicine Galveston, TX Stanford, CA 2 RPA Clinical Practice Guideline #3 Appropriate Patient Preparation for Renal Replacement Therapy Eugene Z. Oddone, MD Douglas C. McCrory, MD, MHS American College of Physicians – Co-Director Duke Evidence-based Practice Center American Society of Internal Medicine Durham, NC Durham VA Medical Center Durham, NC Joseph A. Coladonato, MD Duke Institute of Renal Outcomes Research & Health Policy Victoria Norwood, MD Durham, NC American Society of Pediatric Nephrology University of Virginia Preston S. Klassen, MD, MHS Charlottesville, VA Duke Institute of Renal Outcomes Research & Health Policy Durham, NC Paul M. Palevsky, MD Forum of ESRD Networks Meenal B. Patwardhan, MD, MHSA University of Pittsburgh School of Medicine Duke Center for Clinical Health Policy Research and Duke VA Pittsburgh Health Care System Evidence-based Practice Center Pittsburgh, PA Durham, NC Sandy Peckens, MSW Donal N. Reddan, MD, MHS NKF Council of Nephrology Social Workers Duke Institute of Renal Outcomes Research & Health Policy Merrimack Valley Nephrology Durham, NC Methuen, MA Olivier T. Rutschmann, MD, MPH Venkateswara Rao, MD Duke Center for Clinical Health Policy Research American Society of Transplantation Durham, NC Hennepin County Medical Center Minneapolis, MN William S. Yancy, Jr., MD, MHS Duke University Medical Center Charlotte Thomas Hawkins, PhD, RN, CNN Durham, NC American Nephrology Nurses Association Rutgers, The State University of New Jersey Burlington, NJ Medical Editor Joseph White Rebecca N. Gray, DPhil American Association of Kidney Patients Duke Evidence-based Practice Center Durham, NC Methodologists Project Manager and Editor David B. Matchar, MD, FACP Director, Duke Center for Clinical Health Policy Research and Emily G. Shurr, MA Co-Director, Duke Evidence-based Practice Center Duke Evidence-based Practice Center Durham, NC Durham, NC RPA Clinical Practice Guideline #3 3 Appropriate Patient Preparation for Renal Replacement Therapy JNC VI Sixth Joint National Committee on ABBREVIATIONS USED Prevention, Detection, Evaluation, and Treatment of High Blood Pressure K/DOQI Kidney Disease Outcomes Quality % Percent Initiative ACE Angiotensin converting enzyme L Liter AHRQ Agency for Healthcare Research and LDL Low-density lipoprotein Quality LPD Low-protein diet AMA American Medical Association LVH Left ventricular hypertrophy ARB Angiotensin II Receptor Blocker m Meter ACVD Atherosclerotic cardiovascular disease mcg Microgram ASN American Society of Nephrology MDRD Modification of Diet in Renal Disease ATP-III National Cholesterol Education Task Force mEq Milliequivalents Adult Treatment Panel - III mg Milligram AV Arteriovenous MedPAC Medicare Payment Advisory BCG Bromo-Cresol-Green Commission BP Blood pressure min Minute BUN Blood urea nitrogen mL Milliliter Ca Calcium mm Hg Millimeters of mercury CHD Coronary heart disease mmol Millimoles C-HPTH Carboxyl-terminal parathyroid hormone NHANES National Health and Nutrition CKD Chronic kidney disease Examination Survey CME Continuing medical education NIDDK National Institute of Diabetes and CMS Centers for Medicare and Medicaid Digestive and Kidney Diseases Services NKF National Kidney Foundation CPG Clinical practice guideline OCSQ Office of Clinical Standards and Quality CPM Clinical performance measure PAERI Prevalence of Anemia in Patients with CPT Current procedure terminology Early Renal Insufficiency CrCl Creatinine clearance PD Peritoneal dialysis CQI Continuous quality improvement PEAC Practice Expense Advisory Committee CVD Cardiovascular disease pg Picogram dL Deciliter PTH Parathyroid hormone EDTA Ethylenediaminetetraacetic acid QALY Quality Adjusted Life Year EPC Evidence-based Practice Center RBC Red blood cell ESRD End-stage renal disease RCT Randomized controlled trial gGram RPA Renal Physicians Association GAP Guidelines Applied to Practice RRT Renal replacement therapy GFR Glomerular filtration rate RUC Relative Value Update Committee h Hour SCr Serum creatinine Hb Hemoglobin SGA Subjective Global Assessment Hct Hematocrit TIBC Total iron binding capacity HDL High-density lipoprotein TLC Therapeutic lifestyle changes HPTH Hyperparathyroidism TSAT Transferrin saturation ICD-9 International Classification of Diseases, UNOS United Network for Organ Sharing Ninth Revision VLDL Very low-density lipoprotein iPTH Immunoreactive parathyroid hormone WHO World Health Organization 4 RPA Clinical Practice Guideline #3 Appropriate Patient Preparation for Renal Replacement Therapy ABOUT RPA tory issues and options in order to act on behalf of our members to protect their ability to practice medicine with minimal regulatory burdens and receive fair com- RPA . the Advocate for Excellence in pensation. Nephrology Practice RPA includes advanced practice nurses, physician assis- Organized in 1973, the Renal Physicians Association tants and practice managers who, as part of the renal (RPA) is a national medical specialty association with a care team, conduct important functions within the membership comprised of healthcare providers in the nephrology practice. Volunteers representing each of subspecialty area of internal medicine known as these group’s special interests communicate with RPA nephrology. RPA represents and serves nephrologists, leaders and staff about how to best address issues that practice managers, advanced practice nurses and physi- arise. cian assistants in their pursuit of quality renal health care. RPA’s members are engaged in diverse activities RPA addresses Medicare, Medicaid and private sector including the practice of medicine, teaching, research health care financing issues. RPA leaders meet with rep- and all are committed to improving the care of patients resentatives of the Centers for Medicare and Medicaid with renal disease and related disorders. Services (CMS, formerly the Health Care Financing Administration) and the carrier medical directors to RPA’s Core Values: address concerns about discrepancies in local carrier policies, documentation requirements, and trends in 1. Commitment to high quality, cost effective, ethical payment denials. renal care 2. Promotion of the interests and professional status of RPA monitors the Medicare Payment Advisory the discipline of nephrology Commission (MedPAC) as well as Congressional health 3. Promotion of the leadership role of the nephrology care financing activities and serves as a resource on profession in defining policy which influences renal-related issues. As an active participant on the renal care American Medical Association (AMA) Relative Value 4. Recognition of and respect for the multidisciplinary Update Committee (RUC), Practice Expense Advisory nature of renal care Committee (PEAC) and Current Procedure Terminology (CPT) Editorial Panel, RPA works to assure that work val- RPA represents nephrologists and is recognized by ues for nephrology services are appropriately deter- national leaders as the organization that sets the stan- mined and that CPT codes accurately reflect nephrology dards for delivering value and accountability for quality clinical practice. renal patient care. The Association’s long-standing advo- cacy program has fostered a close working relationship RPA tracks problems related to reimbursement for with federal agencies and other organizations involved nephrology services and payment denials experienced in health care policy development and implementation. by members to determine trends and identify areas RPA regularly meets with and advises key government where the Association