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Thomas H. Lee, MD, MSc, interviews Jeffrey Giullian, MD, MBA, Chief Medical Officer for DaVita Kidney Care.
Tom Lee:
This is Tom Lee, Editor-in-Chief with NEJM Catalyst, talking today with Jeff Guillian, who is the Chief Medical Officer for DaVita Kidney Care. We were in a small meeting recently when Jeff was commenting on the challenges providing equitable care for patients with end-stage renal disease (ESRD), and I came away with the realization that equity has to be pursued at the front lines of care and on a condition-specific basis. That’s where the challenges exist and are understood, and we hope can be addressed.
Jeff was good enough to join us to share his thoughts on all three of those issues: the nature of the challenges, why they exist, and what might work. Jeff, before we plunge into those three things, can you give our listeners some basic background so they can put your comments in context?
Jeffrey Giullian:
Hello, Tom. It’s great to be with you. It was nice seeing you recently. By way of background, I’m a nephrologist from Denver. I practiced both general and transplant nephrology up until a few years ago when I transitioned from the bedside, or chairside, to focus more on population health management and holistic care for persons living with kidney disease. I’ll tell you, I never set out to be a nephrologist. The truth is — and I don’t tell many people of this — I didn’t do so well in renal pathology as a medical student; I didn’t really enjoy it. But then, as things go, I had the opportunity to work with truly a spectacular nephrologist early in my internship and I fell in love with the specialty. Now, as Chief Medical Officer at DaVita, my focus is on patient safety, comprehensive care, equity, and patient experience.
Lee:
We won’t plunge into the anion gap today. Instead, we’re going to ask you to characterize the challenges of making care more equitable in ESRD.
Giullian:
I’m glad you’re not quizzing me on anion gap. Importantly, equitable care for persons with kidney failure is more than just a nebulous goal; I think of it as a responsibility. Chronic kidney disease and end-stage kidney disease disproportionately affect persons of color. No question about that. The statistics are heart-wrenching when you jump into them: Three times more Black people develop kidney failure compared to white people.1 Hispanics also have a higher rate than their white counterparts1 — and that matters to me personally, as my wife and her family are Hispanic. And people of color tend to have less access to care for chronic kidney disease, and when they do get access, it tends to be later in the course of their illness.1 They generally receive less education about kidney health, and subsequently we see that they end up having fewer choices in their treatment options.1 Then, of course, if they do unfortunately go on to develop full kidney failure, they’re 30–40% less likely to have the opportunity to dialyze at home2 and they are significantly less likely to get a kidney transplant.3 Again, something that is near and dear to my heart. Especially to get a living donor transplant, which we know is the best possible treatment option for someone living with kidney disease.
Chronic kidney disease and end-stage kidney disease disproportionately affect persons of color. No question about that. The statistics are heart-wrenching when you jump into them.
Lee:
These issues are really complicated. What are some of the major root causes of the forms of inequity that you described?
Giullian:
The root causes of inequity are truly varied. Some are obviously more controllable than others, but when we think about the controllable factors and when we think about their solutions, I categorize them [as] falling into three buckets. The first big bucket is socioeconomic factors and social determinants of health, things like access to the right nutrition and transportation and health literacy. Our dietitians, our social work team, and our adult education experts, they work every single day to address those factors, including providing tactical education about kidney health and comorbidities associated with kidney disease. This includes education that is not just geared to patients, but importantly it’s geared to their loved ones and caretakers as well.
The second big bucket is access to care, especially in chronic kidney disease. We are pretty fortunate in this country [United States] that access to care in end-stage kidney disease is not limited, given there is universal insurance coverage through the government for people on dialysis, but that is not necessarily true upstream when, as physicians, we’re probably more likely and able to intervene and slow progression. In this second big bucket, it includes diagnostic testing, things like creatinine and estimated GFR (glomerular filtration rate), that with the algorithms that are out there may overestimate true kidney function in some African American patients.4 This can lead to delayed diagnosis. It can lead to limited access to preemptive kidney transplants. We’re fortunate right now. We are living in a time when the kidney community, which has been led by the National Kidney Foundation and the American Society of Nephrology, have launched task forces that now address these specific issues, and eGFR calculation is changing.
The third big bucket is trust in the health care system. This is both systemic and structural. As you are aware, Tom, this big bucket is deeply rooted, but it doesn’t mean that we as physicians and as health care leaders shouldn’t address it. Now is the time, and it’s a call to action for every single one of us to take responsibility.
Lee:
A call to action is compelling, but it’s overwhelming, too. What do we do, or, more accurately, what are you doing?
Now is the time, and it’s a call to action for every single one of us to take responsibility.
Giullian:
We, and a lot of us in the kidney community, are addressing health equity head on. In many ways, there are positive stories out there where our community has achieved greater equity, including in the Medicare quality rating system, which some of us refer to as the dialysis five-star program. Current data demonstrates trends of greater equity among dialysis facilities across the zip codes of varying demographics.5 That’s a great start, but of course, we wouldn’t say that that’s enough. It is the foundation. It provides the momentum to continue our efforts, and it has given me confidence that we’re pointed in the right direction.
Right now, we are focusing on inequity in four domains of kidney care: chronic kidney disease — [that’s] early and moderate kidney disease — access to kidney transplants, access to home dialysis options, and then, importantly, quality of life as well. In each of these domains, we are working to uncover and understand specific root causes of inequity. We’re identifying potential biases, which might be clinical or otherwise, and we’re trying to create awareness of health equity across our entire organization. We’re addressing these head on, and we know that to do this, we have to earn the trust of our patients and earn the trust of their loved ones, regardless of their background, because we’ve got to empower them to take control of their disease rather than letting kidney disease control them, and letting diabetes and hypertension and all of the underlying factors control them.
What we’ve been doing is we’ve been expanding our culturally sensitive patient education platforms. We’ve been providing cultural humility and unconscious bias training to help our care teams so that they can deliver personalized care. And then to the extent that we can, we are working to address social determinants of health directly in our clinics and through political advocacy and community partnerships. I know for sure that we are not going to be successful alone. If we’re going to move the needle on this, we’ve got to broaden our impact. We have a term for that around here. We call that “spreading ripples,” and what it means is we’re committed to sharing our progress. We are committed to sharing our learnings and even our failures with others in the community so that we can join voices on health equity.
Lee:
This is why I was so interested when you made your remarks at the meeting we both attended. You spoke about broad, soft issues like building trust, but with specific focuses like increasing rates of transplantations, increasing rates of home dialysis. I know it’s early. It’s early for all of us. We’re all learning, but how’s it going so far?
Guillian:
I would say you’re exactly right. I’m learning every single day, but I will share a little bit of inspirational data. In the early months of last year, of 2021, when Covid-19 vaccines first became available, we began to notice worrisome trends of inequity among our Black and Hispanic patients. They were initially around 40% less likely to receive the Covid-19 vaccine.6 At that time, access to the vaccine was limited; it was truly a scarce resource, and you coupled that with the political climate of the time. There were trust issues because it was a relatively new vaccine technology and, quite frankly, there were side effects and that was getting blown up in the press. What we were seeing was inequality develop in real time right in front of our eyes. Here were communities that were devastated by the Covid-19 virus, and these people weren’t getting vaccinated at the same rates as white people and Asian people.
We’ve been providing cultural humility and unconscious bias training to help our care teams so that they can deliver personalized care.
Through grassroots efforts, and by tweaking our educational efforts and by calling out those differences and putting a name to it, we were able to engage our frontline caregivers. We were able to engage patients. We were able to engage different communities. And we were able to shrink and then actually nearly close that vaccine gap entirely.6,7 That’s a success that we’re now using to snowball our efforts.
We’ve partnered with a start-up company by the name of SameSky Health, a leader in addressing health equity, to help us meet the needs of our patients. We’ve gone back and redoubled our efforts to make sure that what we’re doing is culturally sensitive, it’s relevant when we educate, and again not just educating our patients, but trying to educate anyone in the community experiencing kidney disease, their family members experiencing kidney disease. This is education on things like diet and blood pressure control and managing diabetes and the items that we know disproportionately affect people, especially people of color, who are experiencing chronic kidney disease and unfortunately moving toward end-stage renal failure or end-stage kidney disease.
We’ve got a saying around here: “We are far from perfect, but we are far from done.” I think that sentiment fully encapsulates our work on health equity. It encapsulates the work we did on vaccine equity, and we have found some success in these areas. We celebrate those successes, but we’ve also identified a number more opportunities in these areas, and we’re going to continue driving relentlessly to close those gaps.
Lee:
One of the sayings that we have around NEJM Catalyst comes from my coauthor and the Co-Chair of our Editorial Board, Michael Porter, who always says, “We should be asking, what’s the unit of analysis at which value gets created?” His point is that when you’re dealing with heterogenous populations, you can only do so much to move the needle, but when you get down to focused populations with shared needs defined by conditions like end-stage renal disease, that’s when you can put together actions that really move the needle on value and equity and other things that you want to improve.
Your focused efforts on your population are important and of great interest. My hope is that what you find [that] can help move the needle in your population, will help us with other conditions as well, and [we] will be adapting the insights that you create. Thanks for your time, Jeff, and your insights and your openness about where we are with this work today. We’ll be following along carefully and hope that you’ll keep us updated.
Giullian:
Thanks so much, Tom. I appreciate the opportunity.
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