May 22, 2006
1676 International Drive
McLean VA 22102
The American Nephrology Nurses Association (ANNA) represents more than 12,000 registered and advanced practice nurses who care for patients with chronic kidney disease (CKD). Our members practice in a variety of roles and settings including direct care to patients on dialysis or receiving kidney transplants, patient education, staff training and development, and home dialysis training and support.
Thank you for allowing ANNA an opportunity to provide input into the Proposed Medication Measures for CKD/ESRD. As the voice of nurses who care specifically for patients with CKD, and as an organization, we had the project plan reviewed by our Hemodialysis, Chronic Kidney Disease and Peritoneal Dialysis Special Interest Groups as well as the ANNA Board of Directors. We are pleased to see the special needs of this population being addressed by The Centers for Medicare and Medicaid Services (CMS) and BearingPoint, Inc. Specifically, we appreciate that this proposed set of medication measures will be used for the purpose of quality improvement and intervention in providing care to the Medicare eligible population with CKD and ESRD. We are particularly intrigued by the proposal feature of data gathered from Part D Prescription Drug claims.
ANNA was pleased to have a representative on The Technical Expert Panel (TEP) that convened in Baltimore on January 26 and 27, 2006. ANNA member and Immediate Past President Suzann VanBuskirk participated on the Panel to assist CMS in the development of the proposed medication measures.
ANNA supports the recommendations included in the Proposed Medication Measures for CKD/ESRD document. We also support using the staging methodology offered by the National Kidney Foundation (NKF) for risk stratification and ICD-9-CM diagnosis codes to identify CKD beneficiaries as detailed in the proposal. In addition, we have several comments outlined below.
The CKD ICD-9-CM codes are new as of October 2005. The proposal advises that it may require some time for the renal community to use these codes reliably. We would like to add that many primary care providers, who see patients in CKD stages 1-3, may not know to use the CKD codes, let alone make a referral to nephrology. It appears to us that the proposal excludes CKD stage 3 for phosphate binder use. However, KDOQI guidelines on bone metabolism and disease support the use of phosphate binders as appropriate therapy for CKD stage 3.
We agree that angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB) are the preferred first line treatment for hypertension in people with diabetes because of their renoprotective characteristics. However, there are still some patients who cannot tolerate them due to adverse side effects. These patients may require other non ACEI/ARB antihypertensive therapies.
We agree that elevated serum potassium can occur in kidney failure and that the use of potassium sparing diuretics which can exacerbate hyperkalemia within this population should be used with caution. We would like to add that there are certain patients with severe congestive heart failure (CHF) who are managed on potassium sparing diuretics and ACEI therapy. Cardiology and nephrology need to closely monitor potassium in these patients. Indeed, the potassium sparing diuretics may be discontinued in the later stages of CKD, but for some patients, these are a cornerstone of CHF management.
Thank you again for the opportunity to participate in this review. We look forward to seeing the results of this interesting project.
JoAnne Gilmore, BSN, RN, CNN
cc: ANNA Board of Directors
Mike Cunningham, Executive Director