kidney disease screening and awareness...
TRANSCRIPT
Kidney Disease Screening and
Awareness Program (KDSAP): a
Model for Potentially Increasing
Workforce in Nephrology
Division of Kidney Disease and Hypertension
Rhode Island Hospital
February 10, 2012
Carol Liu
Harvard College, Class of 2013
Li-Li Hsiao, M.D., Ph.D. FACP
Renal Division, Brigham and Women’s Hospital
Harvard Medical School
Disclosure Li-Li Hsiao 1. Community Kidney Disease Detection program (CKDD)
• SDSC Global Foundation
• Genzyme
• Rotary Club, Da-An, Taipei, Taiwan
2. Grant/Research support: Abbott
3. Consultant: none
4. Speakers Bureau: none
5. Major stock shareholder: none
6. Other Support, Tangible or intangible: none
Carol Liu Nothing to disclose
Overview
• Epidemiology of CKD
• Challenges of battling CKD
• Kidney Disease Screening and Awareness
Program (KDSAP)
• Role of KDSAP in nephrology workforce
• Boots on the ground-training the next
generation Nephrologists
Kidney Disease Screening and
Awareness Program (KDSAP): a
Model for Potentially Increasing
Workforce in Nephrology
Division of Kidney Disease and Hypertension
Rhode Island Hospital
February 10, 2012
Carol Liu
Harvard College, Class of 2013
Li-Li Hsiao, M.D., Ph.D. FACP
Renal Division, Brigham and Women’s Hospital
Harvard Medical School
Chronic kidney disease (CKD):
a major health problem in the U.S.
Incidence of ESRD, 2009 (USRDS 2011 ADR Figure 12.3, vol 2)
• 14.5% of the U.S. adult population has CKD (USRDS 2011 ADR NHANES 2005-2008)
• In 2004, ~500,000 Americans suffered from ESRD, a number projected to reach 1.8 million by 2020 (Collins 2007;
Grassman 2005)
Comparison of unadjusted ESRD prevalence &
incidence worldwide
USRDS 2011 ADR Figure 12.1 vol. 2
Prevalence of CKD has increased
throughout most of the U.S.
Geographic variations in adjusted prevalence rates of ESRD (per million
population), by HSA
1998
USRDS 2010 ADR, Figure 2.11, vol 2
Prevalence of CKD has increased
throughout most of the U.S.
Geographic variations in adjusted prevalence rates of ESRD (per million
population), by HSA
2003
USRDS 2010 ADR, Figure 2.11, vol 2
Prevalence of CKD has increased
throughout most of the U.S.
Geographic variations in adjusted prevalence rates of ESRD (per million
population), by HSA
2008
USRDS 2010 ADR, Figure 2.11, vol 2
0
10
20
30
40
50
Stage 3 Stage 4
Men
Women
Low patient awareness of CKD
Men
Men
Women
Women
Aw
are
of
Weak o
r F
ailin
g K
idn
eys, %
Coresh J, et al. JAMA 2007 Nov 7;298(17): 2038-47
Point prevalent distribution & annual costs of (fee-for-service) Medicare patients, age 65 & older, with diagnosed diabetes,
CHF, & CKD, 2009 Figure 6.1 (Volume 1)
Populations estimated from the 5 percent Medicare sample using a point prevalent model (see Appendix
A for details). Population further restricted to patients age 65 & older, without ESRD. Diabetes, CHF, &
CKD determined from claims; costs are for calendar year 2009.
USRDS 2011 ADR
Cost of CKD in USA
0
1
2
3
4
5
Whi
te
Black
His
panic
Whi
te
Black
Nativ
e Am
erican
Asian
His
panic
Minorities suffer from a higher prevalence of
ESRD
USRDS 2010 ADR
Hsu CY, et al. J Am Soc Nephrol 14: 2902-2907, 2003
0
1
2
3
4
5
White
Bla
ck
Hispa
nic
White
Bla
ck
Nat
ive
Am
erican
Asian
Hispa
nic
Relative prevalence of ESRD
Shortage in Nephrology Workforce
• Greater demand for renal care
• Rising prevalence of CKD
• Aging population in the U.S.
• Waning interest in nephrology as a career choice
• Only subspecialty to attract fewer trainees in 2009 than in
2002
RESULT: Increasing shortage of nephrologists
AAMC estimates shortage of 91,500 physicians by 2015
Mehrotra R, et al. Implications of a nephrology workforce
shortage for dialysis patient care. Semin Dial. 2011
The Challenges of CKD
1. Rising prevalence of disease
2. Low patient awareness
3. Underserved minority groups
4. Shortage of nephrologists
Our Response: KDSAP
• Student-run organization at Harvard College, founded by
undergraduate students in 2008 with the support of Dr.
Li-Li Hsiao
• In collaboration with nephrologists at the Brigham and
Women’s Hospital Asian Renal Clinic
• Has 4 chapters: University of Medicine and Dentistry of
New Jersey, University of Toronto, North Quincy High
School, Brookline High School
KDSAP Objectives
Community Outreach
• Health Screenings
• Health Education
Student Development
• Leadership
• Mentorship and
Career Exposure
KDSAP Objectives
Community Outreach
• Health Screenings
• Health Education
Student Development
• Leadership
• Mentorship and
Career Exposure
Community Kidney Disease Detection (CKDD)
Community Outreach: Health Screenings
1: Registration 3: Health Education
6: Urinalysis
4: BMI + Waist Circ.
7: Blood Glucose 8: Physician Consult
5: Blood Pressure
2: Questionnaire
Community Outreach: Health Education
English Chinese Spanish
Sample powerpoint presentation slides
Educational brochure
Kidney
Ureter
Bladde
r Urethr
a
腎臟
輸尿管
膀胱 尿道
Riñón
Uréter
La vejiga Uretra
KDSAP Objectives
Community Outreach
• Health Screenings
• Health Education
Student Development
• Leadership
• Mentorship and
Career Exposure
KDSAP Objectives
Student Development
• Leadership
• Mentorship and
Career Exposure
Student Career Development:
Leadership
1. Serving as a board member
Board Positions:
Co-presidents
Secretary
Treasurer
Directors of Community Outreach
Directors of Health Advocacy
Directors of Programming
Publicity Manager
Student Career Development:
Leadership in the community
3. Serving as a health screening manager
or station leader
2. Establishing connections with
community leaders
4. Giving health education talks
5. Presenting at conferences and meetings
Student Development:
Mentorship and Career Exposure
• “Meet the Professor” colloquium
• “Meet the Patient” colloquium
• Blood Pressure Training Workshops
• Clinical Shadowing
• Hierarchical Mentoring
• Universal Precaution and Professionalism
(UPP) Training
Results
• Screened and educated over 4000 community members
in 21 different communities across Massachusetts
• Subscribed membership of more than 250
undergraduates since 2008
• Broad representation of student volunteers, ranging from
high school to graduate/medical students.
• 134 students successfully trained & certified for BP and
UPP
Student Volunteers Demographics
Primary Concentration Research Future Career Plan
Natural
Sciences
33 (85%)
None 12 (30%)
Considering
Medicine
32 (82%)
Social
Sciences
5 (13%)
Clinical
Research
3 (8%)
Not
Considering
Medicine
7 (18%)
Humanities 1 (3%)
Basic
Research
24 (60%)
Student Volunteers Demographics
(cont.)
Year of
Graduation
Years in KDSAP Health Screenings
Attended
2009 1 (3%) 0-1 13 (33%) 0-1 12 (31%)
2010 9 (23%) 1-2 15 (38%) 2-3 13 (33%)
2011 7 (15%) 2-3 9 (23%) 4+ 14 (36%)
2012 9 (23%) 3-4 2 (5%)
2013 10 (26%)
2014 3 (8%)
KDSAP Positively influences student career
development in nephrology
Comments
• On obtaining knowledge of the kidney… • “Working at the urinalysis table, I was initially uncomfortable
handling the urine samples. Once I learned about the wealth
of information that we could collect from the simple urine test,
however, I became amazed by the value of the tests, and
handling the urine samples and working the machines
became exciting.”
• On influencing career choice… • “While KDSAP has not made me certain that I want to be a
nephrologist, it has made me much more aware of, informed
about, and interested in nephrology.”
Comments (cont.)
• On engaging in community health… • “KDSAP has offered me a unique opportunity to become
involved in a community and make a difference in a tangible and visible way. It has changed my perspective on medicine and has allowed me to discover the beauty of interacting with patients who have interesting backgrounds and life stories to share. The screenings have been personally fulfilling and enlightening.”
• On gaining leadership experience… • “A board position in KDSAP means a lot more than
leadership in an undergraduate setting. It provided me the opportunity to work alongside community representatives, doctors, medical students, and high school students. I have sharpened my communication skills and team building abilities while overseeing grant applications, helping with volunteer recruitment and directing screening stations.”
Career Trajectory of KDSAP Members
Career Trajectory # of Members
Nephrology as Career Choice 1
Chronic Kidney Disease (CKD)
Research
1
Acute Kidney Injury (AKI) Research 1
Focal Segmental Glomerularsclerosis
(FSGS) Research
1
Kidney Stem Cell Research 1
Polycystic Kidney Disease (PKD)
Research
2
History of Medicine Research 1
Summary
• CKD is a major public health problem with
low patient awareness and racial disparities.
• Nephrology faces a workforce shortage to
care for CKD patients.
• KDSAP raises awareness of CKD and
identifies at-risk individuals through its
community outreach activities.
• KDSAP has a strongly positive influence on
students’ interest in nephrology.
Conclusion
• As an undergraduate organization, KDSAP is able to
make a lasting impact on the community as well as on
students’ career choices.
• High and steady level of volunteer commitment enables
KDSAP to keep expanding.
• Positive exposure to nephrology can influence
undergraduate students’ career decisions.
• KDSAP is a model for potentially increasing the
nephrology workforce.
Conclusion (cont.)
• A physician adviser, in particular a nephrologist, is
instrumental for KDSAP’s success.
• A nephrologist adviser’s role:
1. Educating students about kidney physiology
2. Securing resources to fund programs
3. Providing mentorship
4. Setting a vision, etc.
Boots on the ground-training
the next generation Nephrologists
Li-Li Hsiao, M.D., Ph.D.
By 2020, the United States will face a
staggering shortage of over 90,000 primary
care and specialist physicians to care for an
aging and growing population
Shortage of Physicians
1. The passage of health care reform in 2010 will bring
an additional 32 million Americans into the
healthcare system by 2014 ( the 2010 Patient Protection and Affordable
Care Act).
2. The Census Bureau projects a 36% growth in the
number of Americans over age 65, the very segment
of the population with the greatest health care needs.
3. The country will lose one third of its physicians to
retirement.
• Greater demand for renal care due to rising
prevalence of CKD and aging population in the
U.S. A.
1. 19.2 million patients with CKD stages 3, 4, & 5
2. 6,400 full-time equivalent nephrologists in 2008 (AAMC 2008)
3. Each nephrologist is required to care for ~2,500 CKD
patients
Shortage in Nephrology Workforce
• United States Medical Graduates (USMGs): Interest in
nephrology as a career is waning (Parker, M.G., et al. CJASN, 2011; Brotherton, S.E., et
al. JAMA 2003; Brotherton, S.E. et al. JAMA 2010)
• Medical students who report minimal exposure to nephrology during their
clinical rotations, believe that the specialty is too complex and uninteresting
• Medical students perceive nephrologists as being overworked and underpaid
• Only subspecialty to attract fewer trainees in 2009 than in 2002
• International Medical Graduates (IMGs): Nephrology
training programs have increasingly relied on IMGs to
fill fellowship positions • Stricter work visa requirements may cause the number of IMGs to decline
(American Medical Association IMG Governing Council, 2010)
Shortage in Nephrology Workforce
• The American Society of Nephrology (ASN)
encourages the “implementation of strategies for
increasing interest among students and residents” (Parker,
M.G., et al. CJASN, 2011)
Shortage in Nephrology Workforce
• A reproducible program
• Relies primarily on student volunteerism and
physician mentorship
• The first to strategically target pre-medical
undergraduate students
• Allows students to explore an otherwise unfamiliar
field early in their careers.
• Cultivating interest in the field of nephrology at the
pre-medical level
KDSAP as a Model for Potentially
Increasing Workforce in Nephrology
Frequent Asked Questions about KDSAP
• What if students joined KDSAP entirely for the
purpose of getting into medical school?
• It takes too long (at least 10 years) to see if KDSAP
had the influence on its members to become
nephrologist.
• How to follow up the participants who have abnormal
results from the screenings?
Career Trajectory of KDSAP Members
Career Trajectory # of Members
Nephrology as Career Choice 1
Chronic Kidney Disease (CKD) Research 1
Acute Kidney Injury (AKI) Research 1
Focal Segmental Glomerularsclerosis
(FSGS) Research
1
Kidney Stem Cell Research 1
Polycystic Kidney Disease (PKD) Research 2
History of Medicine Research 1
Brookline, MA Massachusetts U.S.
White $97,577 $67,590 $54,535
Black $42,188 $41,374 $34,445
Hispanic $54,167 $32,205 $40,946
Asian $80,769 $73,159 $68,458
One Race, Other $25,385 $31,829 $40,521
Two or More Races $51,442 $47,629 $45,012
Nephrologist in making among
High School Students
•We did some research on the groups most susceptible to kidney disease, finding this:
African Americans, Hispanic Americans, Native Americans and Asian Americans are more at risk for kidney disease.
And, I remember, you guys also told us something similar.
•The demographic breakdown in Brookline is as follows:
3.4% Black or African American, 0.12% Native American, 15.6% Asian, 0.03% Pacific Islander, 1.01% from other races,
and 2.18% from two or more races. 5.0% of the population were Hispanic or Latino of any race.
Initial “Needs Assessments” performed by high school students
supervised by Nephrologist:
Shortage in Nephrology Workforce
What can a Nephrologist do?
• Help establishing KDSAP in your area • Serves as an advisor
• Volunteer in community out-reach activities
• Participate in “meet the professor” series
• Bring your patients to the “ meet the patient” series
• Allow students to shadow you in clinical setting
Be a mentor!!!
Few of my thoughts: • Rewarding “teachers”: grants for being an educator
• Giving CME credits for volunteerism in community
• Incorporating community service into fellowship training
program
Shortage in Nephrology Workforce
How do we recruit Nephrologists?
Acknowledgements • Jennie Kuo
• KDSAP Chapters • Harvard University
• Brookline High School
• North Quincy High School
• Community leaders
• Dr. Connie Rhee
• Dr. Julie Paik
• Dr. Tzong-shi Lu
• Dr. Kenneth Lim
• APAMSA, HMS
• National Kidney
Foundation-KEEP
• Renal Division, BWH