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The changing landscape of the nephrology nursing care environment in the United States over the last 45 years.

Forty-five years have passed since the inception of the association that has become the American Nephrology Nurses' Association (ANNA). In 1969, one of the earliest specialty nursing organizations was created and named the American Association for Nephrology Nursing (AANN) (Counts, 2006). The organization focused on a broad range of nephrology nursing, including transplantation, home therapies, peritoneal dialysis, and chronic hemodialysis, as well as nutritional considerations and psychiatric effects of therapy (Hoffart, 1989a). The overall purpose was "to promote knowledge about the care of patients with renal disease," and the association offered full membership to only registered nurses (AANN, 1969, p. 1). The name changed to the American Association of Nephrology Nurses and Technicians (AANNT) in 1970, and full member status was granted to LPNs and technicians in addition to registered nurses (Hoffart, 1989a). The name was again changed in 1984 to the current name of the American Nephrology Nurses' Association (ANNA), reflecting a bylaws change restoring the original full membership approach (McCulloch, 1989).

Significant clinical, technological, demographic, and economic changes have had an impact on the end stage renal disease (ESRD) program and nephrology nursing over time. This article focuses on the growth of the ESRD program, technological advances, costs of care, providers, and changes within the patient's demographics and the nurses who care for them. As Confucius said, "Study the past if you would define the future."

Technological Advances And Nephrology Nursing

By the time the association was formed, numerous extraordinary historical events had taken place in the nephrology community in both hemodialysis and peritoneal dialysis, and many more advances followed. Nephrology nurses were at the frontlines of innovation and patient care.

Hemodialysis

The artificial kidney had been constructed, modified, and used in Europe, Canada, and the United States in the late 1940s (Coleman & Merrill, 1952; McBride, 1987). Willem Kolff had performed the first successful dialysis treatment using a rotating drum kidney made of cellophane in 1945. The equipment was improved upon, and additional Kolff-Brigham models were shipped from Boston between 1954 and 1962 to other hospitals worldwide.

The first successful arteriovenous (AV) vascular access, a Teflon[R] shunt, had been developed by Belding Scribner, Wayne Quinton, and David Dillard in 1960 allowing hemodialysis to be provided on an ongoing basis (Quinton, Dillard, & Scribner, 1960). At that time, chronic hemodialysis was initiated for the first patient in the United States who survived for 11 years on dialysis. The first treatment lasted 76 hours using a Skeggs-Leonards dialyzer, a Teflon shunt, a blood flow of 100 to 130 mL/minute, and a continuous flow of dialysate from a chest-type freezer holding 300 liters of dialysate.

Although significant scientific and technological advances had been made prior to the founding of the association, impressive progress con tinued from 1969 onward that had a profound impact on nephrology nursing.

Vascular access. After the revolutionary creation of the Quinton-Scribner AV shunt, the first chronic vascular access, other types of vascular access devices and techniques were introduced. In 1961, Stanley Shaldon inserted catheters into the femoral artery and vein using the Seldinger technique for immediate access (Konner, 2005). He later used only femoral veins, eliminating the need to use the higher risk femoral artery, or used subclavian veins (Konner, 2005). It is interesting that today, temporary catheters, although quite different from the those used by Dr. Shaldon in 1961, are still sometimes referred to as "Shaldon" catheters (Konner, 2005).

In 1966, another team made up of James Cimino, Michael Brescia, Baruch Hurwick, and Kenneth Appel, the surgeon who performed the surgical procedure, published their landmark work describing their Brescia and Cimino AV fistula, forever advancing the types of chronic accesses available (Brescia, Cimino, Appel, & Hurwick, 1966).

In the early 1970s, TJ. Buselmeier introduced another AV shunt that gained some acceptance, particularly for pediatric patients (Konner, 2005). Shortly thereafter, AV grafts were developed for patients with inadequate native vessels with materials ranging from bovine carotid arteries and umbilical cords to synthetic materials (White, 2006). Over the next decade, AV shunts were replaced with long-term indwelling catheters. Devices were developed that allowed the use of a single lumen catheter during dialysis. This was followed by the development of the double lumen catheters that are still used today. A growing nephrology community concern remains about the higher infection-related mortality, hospitalizations, and costs associated with the chronic use of hemodialysis catheters (Parker, Hakim, Nissenson, Steinman, & Glassock, 2011).

Nephrology nursing care in the 1970s focused on preserving the vascular access and preventing complications, including infections, clotting, disconnections, or dislodgement of the shunt tips or needles used with AV fistulae and grafts. Nursing care of the AV shunts required meticulous attention to aseptic technique (White, 2006). Nephrology nurses also routinely performed AV shunt declotting procedures by aspiration or in some geographic areas by using Fogarty catheters to withdraw the clot. In addition to the infection prevention and technical aspects of access preservation, nephrology nurses had to have astute assessment skills and focus heavily on teaching the patient and family members on how to care for their vascular access--their lifelines for dialysis.

Now, decades later, the nephrology nursing techniques that began in the 1960s and 1970s, including strict adherence to infection prevention practices, sharp assessment skills, precise technique, and diligent patient teaching, are still very important today. It is imperative that nursing processes remain focused on maximizing blood flow, minimizing complications (including infections), promoting long-use life, and educating patients and their families (Gomez, 2011).

The artificial kidney. The first artificial kidney incorporating all basic elements common to today's artificial kidneys was created by Abel, Rowntree, and Turner in the early 1900s using a long cylindrical unit with stoppers at each end and collodian tubes in its center (McBride, 1987, 1989). Multiple designs followed beginning in the 1940s, including Kolff's rotating drum using cellulose acetate sausage skin, Alwall's vertical drum kidney, the Kolff-Brigham rotating drum using cellophane, and the Skeggs-Leonard parallel plate dialyzer (McBride, 1987, 1989). The first dialyzer made of a cuprophan membrane was the Kiil dialyzer, a parallel plate dialyzer resembling the Skeggs-Leonard device (McBride, 1987). The first commercially available, completely disposable dialyzer was a twin-coil device with a 1200 to 1800 mL priming volume (McBride, 1987).

The artificial kidney significantly changed in 1967 with a regenerated cuprammonion cellulose membrane available not only in sheets, but in tubing that was used to produce smaller-volume coil dialyzers with greater efficiency (McBride, 1987). By the 1970s, improvements had been made in coil dialyzer design, and several sizes were available.

Nephrology nurses in the 1970s utilized various coil and plate dialyzers that required close observation and a high level of skill in responding quickly to dialyzer membrane reactions and ruptures resulting in significant blood loss, severe hypotension, and blood exposure of staff members. Building on the historic milestone of Richard Stewart's development of the hollow fiber dialyzer in 1964 (McBride, 1987), capillary flow dialyzers became available in the late 1970s, reducing the magnitude of membrane ruptures. In subsequent years, membrane technology advanced further, and newer, more biocompatible hollow fiber membranes with greater efficiency became available. Today, many choices of hollow fiber dialyzers in size and membrane type are available.

The practice of reusing hollow fiber hemodialyzers has been widespread in the United States with acknowledged economic benefit, decreased generation of biomedical waste, and prevention of first use syndrome (Upadhyay, Sosa, & Jaber, 2007). Reuse has also been associated with increased health hazard from germicide exposure and disposal (Upadhyayet al., 2007). The number of facilities practicing reuse has significantly changed over the years. In 1976, 18% of facilities had reuse programs; by 1997, the percentage had increased to 82% but decreased to 62% in 2002 (Finelli, Miller, Tokars, Alter, & Arduino, 2005). However, reuse has significantly declined in the last decade to 60% in 2002 and approximately 40% in 2005, with many facilities no longer reprocessing hemodialyzers (U.S. Renal Data System [USRDS], 2013; Upadhyay et al, 2007).

Hemodialysis equipment Hemodialysis equipment had progressed by the late 1960s with proportioning pumps to make dialysate from concentrates in a system that could serve several stations (Blagg, 2007). In 1968, an integrated recirculating single pass batch delivery system, the RSP[R], was made available (McBride, 1987). Safety features were added to the RSP, including a temperature gauge, a positive pressure monitor mercoid switch, and a flow meter (McBride, 1987). The determination of the safety of the dialysate was all done manually, external to the machine itself.

Although the equipment in the late 1960s and early 1970s had a few rudimentary safety features, nephrology nurses had to have keen assessment skills and be extremely alert to possible serious and fatal complications. These included air emboli, dialysate errors, and physiologic reactions to the acetate concentrate used at the time, in addition to massive blood leaks from coil and plate dialyzers previously mentioned.

Over the years, much progress has been made to the hemodialysis equipment, concentrates, and blood tubing. Bloodlines are now equipped with Luer Lok[TM] connections to minimize disconnects. Hemodialysis equipment is now much more advanced to detect air or foam, and blood tubing clamping devices to prevent air, if detected, from being returned to the patient. The equipment is also equipped with both negative and positive pressure monitoring devices, heparin pumps, in-line conductivity alarms, water deaeration systems, heating devices, blood leak detectors, and ultrafiltration controllers. The dialysate is made of more physiologic bicarbonate and acid concentrate that is much better tolerated by patients. The dialysis industry has instituted strict water treatment guidelines mandated by the Centers of Medicare and Medicaid Services (CMS) for all dialysis providers that have improved the quality of the water used to mix with the concentrate to create the final dialysate (CMS, 2008).

Hepatitis B surveillance and infection control. In the late 1960s and early 1970s, infection control and prevention, particularly hepatitis B precautions, were quite different compared to today. In fact, the hepatitis B virus (HBV) was not discovered until 1963 by Dr. Baruch Blumberg who won the Nobel Prize for its discovery (Blumberg, 1976). He had identified a surface antigen for hepatitis B in the blood of an Australian aborigine, thus, the term Australian Antigen (Blumberg, Gerstley, Hungerford, London, & Sutnick, 1967), also referred to as hepatitis-associated antigen (HAA) (Gitnick, 1972).

After the breakthrough finding of the antigen, a blood test was developed, and in 1971, blood banks implemented its use to screen blood donations for HAA (Hepatitis B Foundation [HBF], 2014). Routine monthly screening for HAA and enzymes in both patients and staff members was common in the 1970s (Cameron & Neff, 1981; Hoge, 1978). Prior to that, routine testing for hepatitis was not possible. In 1974, the incidence of newly acquired HBV infection among patients on chronic hemodialysis in the United States was 6.2%, and in some dialysis centers, there were rates reported as high as 30% (Centers of Disease Control and Prevention [CDC], 2001). National guidelines from the CDC for the control of hepatitis B in hemodialysis centers were first published in 1977, and by 1980, there was a sharp reduction in the incidence of HBV infection in both patients and staff members (CDC, 2001). In 1980, the incidence was down to 1% from 6.2% in 1974.

Blumberg's initial discovery led to the development of the first commercially available hepatitis vaccine, approved for human use in 1981 and made from inactivated hepatitis B virus from infected donors (HBF, 2014). In 1982, the CDC recommended hepatitis B vaccination for all susceptible patients and staff members (CDC, 2001). A synthetic hepatitis B vaccine became available in 1986 (HBF, 2014), making the inactivated vaccine obsolete. Prior to the vaccination, prevention was limited to hepatitis precautions (Hoge, 1978) and treatment with gamma globulin, if exposed. The percentage of patients who received HBV vaccination increased from 5.4% in 1983 to 56% in 2002, while the percentage of staff members who received HBV vaccination increased from 26.1% in 1983 to 90% in 2002 (Finelli et al., 2005).

The incidence of hepatitis B in patients on chronic hemodialysis has progressively decreased over the years, from 6.2% in 1974 to 0.06% in 1999 (CDC, 2001). Symptomatic acute HBV infections in the United States in the general population have declined approximately 85% from the early 1990s to 2009, following the adoption of universal infant vaccination and catch-up vaccinations for children and adolescents (CDC, 2012).

Today, in the ESRD arena, there are vaccinations available to prevent acquiring hepatitis B and methods to test the blood for hepatitis B antibodies and antigens. There are national guidelines for infection control and prevention, including hepatitis B precautions from the CDC that have been incorporated into the CMS mandatory conditions for coverage for ESRD facilities (CMS, 2008).

Peritoneal Dialysis

Like hemodialysis, peritoneal dialysis has also benefited from technological advances. Sterile peritoneal dialysis solution became available in 1959, and using polyvinyl bags to hold the solution (instead of glass bottles) gained FDA approval in 1978 (Prowant, 2004).

Access has become the key to successful chronic peritoneal dialysis just as it has with hemodialysis. In 1964, a silicone catheter was designed for chronic peritoneal dialysis access, but the major advance came in 1967, when Tenckhoff developed an indwelling double-cuff silicone catheter, which is still used today (Oreopoulis & Thodis, 2010).

In 1975, Popovich and Moncrief developed a new technique of continuous ambulatory peritoneal dialysis (Sorrels, 1979). Advances in peritoneal dialysis continued, and in 1981, DiazBuxo and colleagues developed continuous cycling peritoneal dialysis (Prowant, 2004). The creation and use of the Y-set decreased peritonitis rates substantially in the 1980s (Oreopoulis & Thodis, 2010). Automated peritoneal dialysis cyclers were developed in the 1980s, and over the years, have become smaller and more user-friendly, and have increasingly improved capacity for the individualization of peritoneal dialysis prescriptions.

Anemia Management

For many years, the limited options for anemia management only included androgens and blood transfusions, with the risk of iron overload, viral or bacterial contaminated products, blood reactions, and transfusion-related errors (Dutka, 2012). In the 1960s and early 1970s, frequent (i.e. weekly) blood transfusions were common (Hoffart, 1989a). However, in some geographic areas like Seattle, Eschback and Adamson recognized that repeated transfusions merely depressed the bone marrow, resulted in iron overload, and perpetuated the need for further transfusions; thus, the administration of blood products began to change (Blagg, 2007). As a result of these scientific studies, patients in parts of the country, such as Seattle, were not transfused except for major blood loss, given supplemental iron only as needed, and generally maintained a hematrocrit in the mid20s (Blagg, 2007). In 1989, a dramatic breakthrough occurred with the availability of recombinant human erythropoietin (rHuEPO), and the treatment of anemia drastically changed for the better and improved patients' lives (Fishbane & Nissenson, 2010).

The Impact of Nephrology Nursing

It is important to recognize the impact nephrology nurses have had on the kidney care community over the years. Barbara Coleman, the first nurse to publish the treatment protocol for patients on the Olsen Rotating Drum Kidney, trained many of the initial hemodialysis staff members in the country on the use of the artificial kidney (McBride, 1989). Since that time, nephrology nurses have penetrated and positively influenced every aspect of the renal community. From holding clinical, education, quality, regulatory, government relations, management, and executive positions in the service sector to having careers in sales, marketing, product development, training, research, service support, and regulatory in the products segment, nephrology nurses have held and continue to hold key roles in advancing the kidney care industry.

The Changing Landscape Of the ESRD Program

The dramatic technological advances were made possible through private and federal funding. In turn, the patient population and provider characteristics also changed significantly.

In 1962, with funding support, the Seattle Artificial Kidney Center (SAKC) opened a three-bed outpatient dialysis center with nurses providing overnight dialysis twice weekly. By 1970, SAKC, renamed the Northwest Kidney Center, released details of the center's operations and their first 175 patients. Overall patient survival was 90% at one year, 85% at two years, and 61% at five years, but in patients 56 years or older, the two-year survival was only 40% (Blagg, 2007). Government funding was not yet available, and funding was a large barrier to providing dialysis therapy.

The first government response to the development of dialysis therapy occurred in 1963 when the Veterans Administration (VA) announced it would establish 30 dialysis units for eligible veterans. By late 1966, home dialysis was becoming established as a preferable alternative to incenter dialysis, and 14 five-year contracts were awarded to demonstrate the effectiveness of training patients and family members to dialyze at home. The overall effect of these changes was that by January 1972, 40% of the patients on dialysis were on home dialysis (Blagg, 1977). In October 1972, Congress passed the Social Security Amendment of 1972. The amendment changed the Medicare law to extend coverage to individuals who were under 65 years of age, had ESRD, and qualified for Social Security benefits. The coverage became effective July 1, 1973.

Over 40 years have passed since the United States Congress passed legislation creating the Medicare End Stage Renal Disease Program. The next section of this article focuses on the growth of the ESRD program, costs of care, providers, and changes in patient demographics.

The USRDS is a national data system that collects, analyzes, and distributes information about ESRD in the United States. It is funded directly by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The information presented below is taken from the 2013 USRDS Annual Report Reference Data Tables (USRDS, 2013).

Incidence Count and Rate

By 1980, the incident count of reported new patients with ESRD initiating some form of therapy was 17,984. By 2011, the incident count had grown to 115,643. Of the 115,643 patients, 112,788 elected some form of dialysis therapy, and 2,855 patients started with a transplant. In 2011, the number of new patients starting therapy on hemodialysis actually declined 1.5%, the first decrease in more than three decades. The population initiating dialysis who selected peritoneal dialysis, in contrast, grew for the third year in a row, and now accounts for 6.6% of patients with a known dialysis modality. This change is associated with the change in Prospective Payment System (PPS) with the incentives for peritoneal dialysis. The growth of incident patients initiating a dialysis modality can be seen in Table 1.

The adjusted rate of new ESRD cases per million population or incident rates has remained stable since 2000, but it fell 3.8% in 2011 to 357 per million population. By contrast, the incident rate in 1980 was 97 per million population. In 2011, the adjusted rate of incident ESRD in pediatric patients was 15.6 per million population. From 2009 to 2011, growth in incident counts and rates dropped across all age groups. With an overall rate for incident patients on dialysis of 349 per million population in 2011, it has been realized that rates vary by network from 228 in Network 16 (Alaska, Idaho, Montana, Oregon, Washington) to 427 in Network 8 (Alabama, Mississippi, Tennessee). By primary cause, rates of incident ESRD have fallen across each of the primary diagnosis: diabetes, hypertension, glomerulonephritis, and cystic disease. Among those whose ESRD is caused by diabetes, disparities persist among young Black/ African Americans. Of new ESRD cases, 44% have a primary diagnosis of diabetes, and 28% have a primary diagnosis of hypertension. In 2011, the incident rates of reported ESRD due to diabetes were the highest among Black/African Americans at 495.6 per million population, whereas the incident rate among Whites was 122.3 per million population, and the rate for the Hispanic population was 316.9 per million population.

Prevalent Population

In 1990, the prevalent population (patients alive on December 31 of each year) was 184,611 patients, including 134,029 on dialysis and 50,582 with a functioning transplant. By contrast, the prevalent population in 2011 totaled 615,899, with 430,273 patients on dialysis and 185,626 patients with a functioning transplant. For 2011, 90,000 patients were waiting for a transplant vs. 24,000 patients on the wait list in 1995. The median time of the transplant wait list for adults is still long at 2.6 years. Overall, the 2011 prevalent population growth was only 3.4% from the previous year and the smallest growth in the last three decades. Further investigation and time are needed to determine if this is a trend. It is amazing to realize that nearly 11 times more patients are now being treated for ESRD than in 1980. The 2011 prevalent hemodialysis population of 430,274 is 52% larger than in 2000, and the prevalent transplant population is 71% higher than in 2000.

Treatment Modality

Since the beginning of almost universal coverage with the Medicare ESRD Program in 1973, the proportion of prevalent patients on home hemodialysis has declined from 6.7% in 1985 to a low of 0.4% in 2001-2004. Likewise, with the development of continuous ambulatory peritoneal dialysis (CAPD) in the late 1970s, the proportion of patients on CAPD rose to 12.5% in 1985. Then, with the development of the continuous cycling peritoneal dialysis (CCPD), the proportion of patients on CAPD/CCPD rose to roughly 15% but has declined over the years, and in 2011, only accounts for 9%.

In 1985, 29,997 incident patients selected dialysis, and 542 had preemptive transplants. Of the 29,997 patients selecting dialysis, 81.6% elected center hemodialysis, and 16.8% elected some form of home dialysis. Of the 84,617 point prevalent patients for the same year, 78.5% were receiving center hemodialysis and 21% were on home dialysis. Beginning in 2000, there was a notable shift in modality selection. Some reasons for the decline in home dialysis were inadequate reimbursement for home hemodialysis, the rapid expansion of dialysis centers, and changing patient demographics resulting from the almost universal Medicare entitlement program (Blagg, 2010). More incident patients were selecting center hemodialysis over home dialysis options. In 2007, of the 108,630 incident patients selecting dialysis, 93.4% selected center dialysis, and only 6.4% selected home dialysis. With the change in reimbursement in 2011, a subtle shift is beginning to take place. Of the 112,788 incident patients selecting dialysis, 91.2% selected center hemodialysis, and 8% selected home dialysis. Likewise of the 430,274 point prevalent patients for 2011, 90.6% are on center hemodialysis, and 9% are on home dialysis.

Mortality and Survival

Improvements in mortality rates have been realized in the incident ESRD population. Between 1993 and 2003, there was little change in first-year death rates in the ESRD population; however, overall mortality rates fell more than 16% between 2003 and 2010. Despite this decline, the high rates of all-cause mortality in the early months of therapy remain high. It has been demonstrated that within the first year of hemodialysis therapy, all-cause mortality peaks in month two following initiation of dialysis and then falls monthly thereafter. Patients on incident hemodialysis in 2010 reached a mortality rate of 440 deaths per 1,000 patient years at risk in month two, then the rate fell to 201 deaths per 1,000 patient years at risk in month 12. Continued research is being conducted in an effort to better understand the cause.

In the prevalent hemodialysis population, mortality rates have declined 26% since 1985 and 21% since 2000. Although the mortality rates continue to improve, patients with ESRD often have multiple comorbidities, and therefore, have a shortened life expectancy as compared to the general population.

Hospitalizations

While all-cause hospitalization rates have declined in all modalities from 1993, the rate of hospitalization due to infection in all ESRD populations has increased 30% greater than those of 1993. For the hemodialysis population, the rate of hospitalization due to infection increased 43% since 1993. The use of dialysis catheters continues to have the largest associated risk. Hospitalization rates related to vascular access for fistula and grafts have declined by 56.6% since 1993.

Admissions for peritonitis have fallen 1.8% since 1993. Transplant has seen a decline in all-cause and cause-specific hospitalization rates with cardiovascular (-39.5%), infection (-4.6%) and all-cause (-15.7%). In 2011, admission rates per patient year for patients on hemodialysis were 1.84, nearly the same to those in 1993. Rates for patients undergoing peritoneal dialysis and transplant have fallen 14% and 15.7%, respectively, from the rates in 1993. Overall hospital days per patient year for hemodialysis and peritoneal have fallen to 11.7 days from 18 days and 15.9 days from 1993 and to 5.7 days for patients who are transplanted.

Costs

In 1973, the estimates of cost for the newly established Medicare ESRD Program varied widely and were understated. According to the National Kidney Foundation (NKF), the first-year cost would be $35 to $75 million; the Social Security Administration (SSA) Office of the Actuary estimated costs of $100 to $500 million the first year (Blagg, 2007). In 1995, the total Medicare costs reported annually or patients with E$RD with at least one claim, by age, gender, race, ethnicity, and primary diagnosis were $8.8 billion and have increased to $34.3 billion. In 2011, 1.4% of Medicare beneficiaries were treated for ESRD and account for 7.2% of the total Medicare spending. In 2010, the total Medicare dollars spent on ESRD by type of service continued to show that inpatient services are the largest expenditure with outpatient care being the second largest expenditure.

In the hemodialysis and transplant populations, total fee-for-service Medicare cost per patient per year (PPPY) were $87,945 and $32,922, and a decline of 0.5% and 0.28%, respectively, in 2010. Peritoneal dialysis PPPY expenditures, however, rose 6.6% to $71,630. These year-to-year changes need further study to determine the cause of this trending; however, they may be caused in part by the 2011 bundled PPS introduction, an overall decline in the hospitalization rates, and the resurgence of home dialysis. The breakdown of total Medicare dollars spent on ESRD by type of service can be seen in Table 1.

ESRD medications are now included in the bundled cost for each treatment, and expenditures for these medications can no longer be assessed. Dosing data continue to be collected from the monthly dialysis claims. ESA dosing fell 20.5% from 2010 to 2011, and an additional 39% in 2012. Likewise, dosing of IV iron fell 14.1% in the first year and 8% the second year, and dosing of IV vitamin D fell 14.3% the first year and 1.4% in the second.

Providers

Technology, the introduction of the 2011 PPS, patient census growth, and the continued proliferation of dialysis clinics have resulted in consolidation of the independent providers (less than 20 centers) and small dialysis organizations (SDOs) (20 to 199 centers) into large dialysis organizations (LDOs). In 1995, the total number of certified dialysis and transplant facilities was 2,160 in contrast to 2011 with 6,009 facilities. The three largest providers own/operate 3,791 of the 6,009 or 63% of all facilities in the United States. Hospital-based facilities treated 36,034 patients in 765 facilities', independent facilities treated 56,339 in 788 facilities, and SDOs treated 49,102 patients in 665 facilities.

According to Nephrology News & Issues' annual dialysis provider ranking for 2013, patient growth for both Fresenius and DaVita went down from double-digit growth in 2011-2012 to single-digit growth in 2013. The overall market share of overall patient population increased about 6.2% during 2012-2013, slightly less than 6.6 % in the 2011-2012 periods. In 2013, the 10 largest providers had a total number of 374,196 patients, of which 9% were on peritoneal dialysis, and 1.5% were on home hemodialysis.

The USRDS reported in the 2013 annual report that standardized hospitalization ratios (SHRs) and standardized mortality ratios (SMRs) in 2011 were similar across providers, with the exception of hospital-based units, in which the SMR was 10.6 % higher than the national average.

Summary

The nephrology landscape has changed significantly over the last 45 years. We are providing more options for patients and utilizing safer and more advanced technology, and remain grounded in a desire to continue to improve.

In a description of the nurse's role during hemodialysis in 1950, responsibilities included technical aspects of the treatment, infection prevention, patient assessment and monitoring, documentation, medication administration, fluid management, patient education, and providing comfort and encouragement (Coleman & Merrill, 1952). Although the manner in which these roles are carried out has changed with time, the skills remain important today. Additionally, despite the technological differences throughout the last several decades, nephrology nursing has remained focused on humanizing the process for people with complex care needs, preserving the patient's dignity, teaching, supporting, and involving the patient and family in their care (Hoffart, 1986b).

Throughout our historical journey, it is apparent that nephrology nurses have always been responsible for a significant amount (or majority) of the care of patients with kidney disease and that nursing care is much more than delivering a treatment (Lynaugh & Fairman, 1989). Nephrology nursing is grounded in patient and family-centered care based on both physiological and psychosocial needs. Nephrology nurses have touched every aspect of the kidney care community shaping the service, government, and product sectors. Nephrology nursing has been vital from the initial development years and continues to be an undeniable force in improving nephrology care to a patient population with very complex patient needs.

Many changes have taken place since the inception of the ESRD program in July 1973. Advances in technology, demonstration projects, research, and reimbursement changes have reshaped the landscape of our care delivery models. In the same way, our knowledge of kidney disease has progressed substantially, resulting in improved diagnosis and treatment in an effort to reduce complications and improve outcomes for patients with ESRD.

Key Words: Hemodialysis, transplantation, home therapies, peritoneal dialysis, nutrition, psychiatric events, history.

Goal

The purpose of this activity is to provide a historical background of the growth of technologies in nephrology and the advances in nephrology nursing.

Objectives

1. Review the inception of the American Nephrology Nurses' Association.

2. List three changes that have improved the delivery of dialysis over the past 45 years.

3. Discuss the impact that nephrology nurses have had on the changes in dialysis services.

This offering for 1.4 contact hours is provided by the American Nephrology Nurses' Association (ANNA).

American Nephrology Nurses' Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center Commission on Accreditation.

ANNA is a provider approved by the California Board of Registered Nursing, provider number CEP 00910.

This CNE article meets the Nephrology Nursing Certification Commission's (NNCC's) continuing nursing education requirements for certification and recertification.

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Barbara Bednar, MHA, RN, CNN, is President and CEO, Reliant Renal Care, Inc., Media, PA; a Past President of ANNA; and a member of ANNA's Keystone Chapter. She may be contacted directly via email at barbara.bednar@reliant renalcare.com

Carolyn Latham, MBA, MSN, RN, CNN, is Corporate Vice President, Clinical Services, Fresenius Medical Care North America; a Past President of ANNA; and a member of ANNA's Music City Chapter.

Statement of Disclosure: The authors reported no actual or potential conflict of interest in relation to this continuing nursing education activity.

Note: Additional statements of disclosure and instructions for CNE evaluation can be found on page 191.

Table 1
ESRD Data

       Incident               Prevalent Patients
       Patients
       Total

                  Total     Center    Center   Home    CAPD
                            HD        Self     HD
                                      HD

1980    17,984    58,190    43,264        0    1,971     880
1981    20,073    66,736    49,098        0     925    2,593
1982    22,564    76,231    54,160        0     769    4,302
1983    25,923    89,416    61,453        0    1,395   6,672
1984    27,558    100,489   65,276        0    2,622   8,704
1985    30,539    111,208   66,419        0    5,681   10,501
1986    33,444    122,860   71,987        0    5,407   11,397
1987    36,902    135,735   79,585        0    4,595   12,287
1988    41,264    149,810   89,338        0    2,966   13,269
1989    46,380    166,631   99,943        0    2,849   14,884
1990    50,865    184,611   110,616       0    2,478   16,795
1991    56,094    205,139   122,345     677    2,325   18,738
1992    61,252    226,043   135,212     763    2,412   20,585
1993    64,455    246,047   148,534     126    1,964   22,374
1994    69,890    268,139   162,615     186    2,008   23,524
1995    70,357    286,116   174,249     503    2,068   22,163
1996    76,335    306,400   189,397     515    2,118   19,936
1997    81,818    327,683   206,585     451    1,788   17,812
1998    87,181    349,981   224,335     347    1,769   15,818
1999    91,282    370,505   239,476     328    1,701   14,410
2000    94,562    391,389   254,621     263    1,598   13,247
2001    97,831    411,166   268,147     311    1,293   12,486
2002    99,994    430,290   280,384     267    1,219   11,637
2003   102,681    448,862   291,772     188    1,341   11,317
2004   105,023    467,880   303,183     179    1,480   10,964
2005   107,298    487,162   314,570     137    1,641   10,918
2006   111,168    508,339   327,451     102    2,110   10,608
2007   111,273    528,999   340,034     141    2,706   10,197
2008   112,835    550,173   353,327     151    3,415   10,028
2009   116,674    573,036   367,628     189    4,107   9,998
2010   117,390    595,818   380,503     182    4,904   10,155
2011   115,643    615,899   389,922     199    5,535   10,147

        Prevalent Patients

        CCPD     Other   Uncertain    Transplant
                 PD      Dialysis     -Total

1980        0    1,359        521        3,790
1981       17     991         362        4,235
1982       47     940         498        5,114
1983       73     819         431        5,876
1984      203     734         698        6,743
1985      540     820         655        7,509
1986      787     724         787        8,889
1987      999     649         973        8,943
1988    1,115     601       1,317        9,246
1989    1,338     548       1,421        9,153
1990    1,976     444       1,720       10,041
1991    2,888     405       1,873       10,272
1992    3,678     341       1,935       10,416
1993    4,287     259       1,905       11,179
1994    5,416     257       2,098       11,509
1995    7,781     213       1,295       12,176
1996    9,485     154       1,045       12,418
1997    10,344    136         959       12,689
1998    10,524    121       1,082       13,624
1999    11,226    103       1,168       13,866
2000    11,864     98       1.204       14,658
2001    12,716     89       1,102       15,263
2002    13,702     98       1,084       15,763
2003    14,428     91       1,047       16,101
2004    14,748    110       1,122       16,968
2005    15,094    102       1,164       17,473
2006    15,483    109       1,194       18,080
2007    16,047     95       1,238       17,531
2008    16,451    116       1,217       17,419
2009    17,437    148       1,247       17,734
2010    19,090    585       1,319       17,781
2011    21,537   1,260      1,673       17,671

        Mortality Rates--
        Unadjusted--1000
        Patient Years at Risk

        Patients   Patients   Patients
        on HD      on CAPD/   with
                   CCPD       Transplant

1980      176.8      237.9        105.3
1981      179.4      212.6        115.6
1982      181.9      219.2         91.7
1983      189.1      240.0         79.2
1984      200.6      207.6         74.3
1985      216.8      221.1         59.6
1986      222.8      227.4         61.6
1987      227.3      232.0         58.5
1988      234.7      240.9         61.0
1989      237.2      220.8         57.0
1990      238.0      219.0         57.1
1991      232.7      214.3         64.9
1992      237.7      215.7         60.9
1993      239.3      222.7         63.2
1994      235.5      218.0         58.4
1995      242.2      224.8         54.5
1996      243.5      228.2         52.2
1997      244.2      222.4         54.4
1998      247.5      220.0         52.1
1999      254.3      217.5         53.3
2000      249.2      211.2         51.8
2001      251.9      202.8         51.0
2002      249.8      195.3         47.9
2003      249.0      188.7         47.1
2004      244.6      184.4         44.1
2005      241.0      174.0         40.8
2006      236.2      169.4         38.0
2007      228.0      156.0         37.7
2008      219.8      154.1         37.1
2009      214.8      148.7         35.1
2010      207.6      140.5
2011      202.8      140.4

        Cost Per Person Per Year

        Patients   Patients   Patients
        on HD      on CAPD/   with
                   CCPD       Transplant

1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991    $41,319    $34,423      $16,193
1992    $44,445    $36,592      $16,466
1993    $46,035    $37,313      $16,855
1994    $48,424    $39,241      $17,776
1995    $49,873    $41,897      $18,661
1996    $53,183    $44,175      $18,835
1997    $53,810    $44,436      $19,006
1998    $53,294    $44,474      $18,200
1999    $53,794    $43,495      $17,448
2000    $55,428    $44,952      $18,494
2001    $58,808    $46,447      $20,142
2002    $61,505    $47,570      $21,236
2003    $63,434    $48,050      $21,862
2004    $66,585    $49,306      $23,725
2005    $68,740    $50,929      $24,670
2006    $73,706    $56,107      $27,993
2007    $75,487    $57,063      $27,772
2008    $81,332    $62,166      $29,934
2009    $85,474    $65,754      $33,266
2010    $87,239    $67,209      $33,103
2011    $87,272    $71,630      $32,922

        Certified    Patients on
        Dialysis     Dialysis--
        Facilities   Year End

1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991        2,148       142,488
1992        2,292       157,354
1993        2,456       171,479
1994        2,624       186,822
1995        2,876       200,162
1996        3,083       214,103
1997        3,344       230,190
1998        3,576       245,710
1999        3,833       259,493
2000        4,013       273,333
2001        4,175       285,982
2002        4,379       298,352
2003        4,530       310,095
2004        4,673       320,404
2005        4,870       332,790
2006        4,997       345,303
2007        5,170       358,095
2008        5,430       371,335
2009        5,689       387,017
2010        5,798       402,054
2011        5,938       414,177

Source: USRDS, 2013.
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Author:Bednar, Barbara; Latham, Carolyn
Publication:Nephrology Nursing Journal
Geographic Code:1USA
Date:Mar 1, 2014
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