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

cliu@college.harvard.edu

Li-Li Hsiao, M.D., Ph.D. FACP

Renal Division, Brigham and Women’s Hospital

Harvard Medical School

lhsiao@partners.org

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

cliu@college.harvard.edu

Li-Li Hsiao, M.D., Ph.D. FACP

Renal Division, Brigham and Women’s Hospital

Harvard Medical School

lhsiao@partners.org

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