John H Crabtree1. 1. Department of Surgery, Southern California Permanente Medical Group, Kaiser Permanente Downey Medical Center, Bellflower, California 90706, USA. John.H.Crabtree@kp.org
Abstract
BACKGROUND: Nephrologists are often thwarted in their attempts to grow their peritoneal dialysis programs because of suboptimal surgeon performance in placing catheters. A rallying call is heard among nephrologists to step up to the role of dialysis access providers. OBJECTIVE: What factors influence the practicability of nephrologists becoming primary dialysis access providers? Why have surgeons failed their task and can anything motivate them to change their performance and improve outcomes? METHODS: While the issues are universal, this analysis focuses on current practice data from the United States. Evidence reviewed includes dialysis center size and annual new starts, profile of specialties performing catheter placement, nephrology workforce capacity, catheter implantation methodology, resource utilization for peritoneal access, and surgeon performance. RESULTS: The current nephrology workforce is running at maximum capacity and fellowship training programs will struggle to meet additional demands. Nephrology training programs are often deficient in providing adequate experience in peritoneal dialysis management. Only 2.3% of peritoneal catheters are placed by nephrologists. The best catheter outcomes are produced by laparoscopic methods used by surgeons. Compared to other catheter placement techniques, laparoscopy enables a larger candidate pool of patients. Nonetheless, suboptimal surgical performances are related to inadequate training, low procedure volume, and poor reimbursement. CONCLUSIONS: It is improbable that nephrologists can expand the scope of their practice to assume the additional role of dialysis access providers. The performance of the existing surgical workforce can be enhanced through medical society-sponsored educational activities, channeling access procedures to designated surgeons, and improved remuneration through outcomes-based incentive programs.
BACKGROUND: Nephrologists are often thwarted in their attempts to grow their peritoneal dialysis programs because of suboptimal surgeon performance in placing catheters. A rallying call is heard among nephrologists to step up to the role of dialysis access providers. OBJECTIVE: What factors influence the practicability of nephrologists becoming primary dialysis access providers? Why have surgeons failed their task and can anything motivate them to change their performance and improve outcomes? METHODS: While the issues are universal, this analysis focuses on current practice data from the United States. Evidence reviewed includes dialysis center size and annual new starts, profile of specialties performing catheter placement, nephrology workforce capacity, catheter implantation methodology, resource utilization for peritoneal access, and surgeon performance. RESULTS: The current nephrology workforce is running at maximum capacity and fellowship training programs will struggle to meet additional demands. Nephrology training programs are often deficient in providing adequate experience in peritoneal dialysis management. Only 2.3% of peritoneal catheters are placed by nephrologists. The best catheter outcomes are produced by laparoscopic methods used by surgeons. Compared to other catheter placement techniques, laparoscopy enables a larger candidate pool of patients. Nonetheless, suboptimal surgical performances are related to inadequate training, low procedure volume, and poor reimbursement. CONCLUSIONS: It is improbable that nephrologists can expand the scope of their practice to assume the additional role of dialysis access providers. The performance of the existing surgical workforce can be enhanced through medical society-sponsored educational activities, channeling access procedures to designated surgeons, and improved remuneration through outcomes-based incentive programs.