Year XVII n. 1/01

The physician working in the public medical system must increasingly deal with patient requests for qualified health services and general managers’ requests of controlling expenses. The nephrologist, even the one that manages ultrasonography, must not be exempted from this effort of combining quality and shrewd management of disposable resources. In this article, I will try to give a contribution to this topic. I will do so by focalizing my attention on the following two points:

1. Ultrasonography as a quality instrument in nephrology.

2. Quality instruments in renal Ultrasound.

Let us begin with some general considerations. Clinical nephrology is one of the youngest medical branches. In fact, it was born about 35 years ago with the success of dialysis treatment and it has just now acquired a well-defined distinction of its fields of competence (acute and chronic renal disease) and of intervention (intensive treatment of acute and chronic kidney failure, haemodialysis, kidney transplant). These fields of intervention form the most solid basis of this branch, in that, for example, nobody doubts that only a nephrologist can provide dialysis treatment. On the other hand, it is undeniable that some friction with other medical branches are emerging concerning certain fields, the competence of which is less defined, such as, for instance, hypertension (with cardiologists) and urolithiasis (with urologists). If we then go and see what the nephrologist actually does in his daily practice, we notice that he programs, interprets and integrates with clinical observation a series of biochemical tests, he carries out and interprets renal biopsies and he utilizes a wide range of information that derives from imaging techniques. Competence implies “know how” and it is the first step of “can do” . Nephrologists are conscientious that, as far as biochemical and immunological assays are concerned, their power is generally weak and conditioned by the relationship with the Units of Clinical Pathology. With regards to renal biopsy, nephrologists may or may not have direct control of the Laboratory that processes the biopsies. As to more complex imaging (CT, MRI and Angiography), nephrologists almost entirely depend on the Department of Radiology, but they have always tried, with some contrasts, to gain direct control of Ultrasonography. Virtually all kidney patients undergoing evaluation in Nephrology Units undergo ultrasound examination. Ultrasonography rapidly distinguishes medical from surgical nephropathies. Consequently, together with urinalysis, it is an essential diagnostic instrument in nephrology. Therefore, no one doubts that Ultrasonography represents a quality instrument in the framing of a nephropathic patient. The problem is seeing who is in charge of this activity. We all know that in the Italian health system, a unique and well-determined model of Renal Ultrasound Unit does not exist. Today, this term represents an organization that may vary from one Nephrology Department to another. For instance, there are some hospitals in which renal Ultrasound is run independently from the Nephrology Units, representing the true Units of Renal Ultrasonography but there are other hospitals where renal Ultrasound is performed with other specialists and others where radiologists or other specialists have the exclusive use of this method. In some hospitals, the nephrologist performs the whole array of ultrasound techniques, from the B-mode test, to transrectal ultrasound, to echo-color-Doppler of renal arteries, and other hospitals, in which, on the contrary, these tests are carried out by other specialists, such as the urologist or the radiologist. However, we nephrologists fundamentally agree on one point, that is that it is preferable that Ultrasonography be directly run by us, though we must recognize that Ultrasonography is not part of the formative curriculum of the nephrologist, neither in Italy, nor in other countries. In other words, Ultrasonography is not regarded as a nephrologist’s specific instrument for his practice and, in postgraduate schools, there are no courses of Ultrasonography for nephrologists. Is it really a good idea that nephrologists are in charge of ultrasound? In order to answer this question, I would like to draw your attention to the two managerial aspects that , in my opinion, emphasize how important it is that nephrologists take charge of this procedure in order “to do”.

1. The first point concerns the managing of time. First of all, Ultrasound is useful in nephrological emergencies. As we have seen, in kidney failure, it serves for the differential diagnosis of medical and surgical nephropathies. In this case, the test is in any case guaranteed within hours, no matter who does it: the nephrologist, the radiologist or anyone else. However, cases in which clinical presentation is that of a medical nephropathy or, in any case, a non acute one, i.e.. When the test can be planned because time is not clinically critical, the nephrologist (when he does not directly perform the examination) must wait 1,2 or more days. The nephrologist or someone else in his place (the secretary or the head nurse) must get in touch with the Department that carries out the ultrasound examination and must often discuss the results again with the physician who performed the test to check their anatomical-clinical compatibility. When Ultrasonography is not directly done by the nephrologist, there are, consequently, “waiting times”, “times of contact” and “times of explanation”. These times cannot be but a waste of resources.

2. These leads us up to the second aspect, strictly connected to the first one, namely the financial question. Operating Units are judged by delivered services (DRG) compared to consumed resources. Well, ultrasound scan furnished by another Department that contributes to produce a certain result (DRG), augments expense because the hospital system will ascribe the cost of the ultrasound scan to the Nephrology Unit. In reality, a Nephrology Unit with 20 beds, that accommodates 700-900 hospitalizations a year, produces DRGs for 3-5 billion lire a year only for the hospital stay. The number of ultrasound examinations performed is generally equal to the number of hospitalizations. The manager of the Unit must be aware of the fact that, with the cost of internal compensation- e.g.-of 100.000 italian Lire for each test, from 70 to 90 million lire, or even more, a year will be spent for Ultrasonography, and that’s not a trifle. Direct supply of ultrasound services by the nephrologist produces savings in time and money. It means, besides “good clinical activity”, also good management of business and internal resources. In the final analysis, it means better “quality” of our services.To answer the previous question, we can, therefore, say that the direct management of Ultrasonography by the nephrologist is a good idea because it represents an important quality factor. At this point, a separate chapter should be opened to discuss if this means that every Nephrology Unit must have its own ultrasound machine or even a Renal Ultrasound Unit, meaning with this latter term space conditions, together with technology and professional resources, oriented to the fulfillment of ultrasound examinations. First of all, I think it is necessary to make some distinctions: We can broadly conjecture three possibilities:

1. Operating Units with remarkable clinical activity.

2. Operating Units with moderate clinical activity.

3. Units exclusively for dialysis treatment.

Now let us closely examine these three models. Operating Units with beds and remarkable clinical activity (e.g. 20 beds, dialysis section, outpatient clinic that embraces the main fields of nephrology, kidney transplant, etc.): in this setting, the standard is represented by the presence of a Renal Ultrasonography Unit, with its own Ultrasound sets (e.g. a high quality instrument that allows to carry out all the ultrasound scans pertinent to nephrology, both in bidimensional mode and color-Doppler, and portable sets for bedside examinations and procedures, such as renal biopsy). The presence of a nephrologist responsible for the Unit is advisable, but it is also necessary that a substantial number of other nephrologists of the same Department be capable of performing all, or at least some, ultrasound tests. If I may try to determine this proportion, I would say that at least 50% of nephrologists, should have these abilities. Whether it is convenient that the Head of the Renal Ultrasonography Unit occupies himself full time or part time in this field should be evaluated on the basis of the availability or resources and of the volume of the activities. The Ultrasonography Unit should also be available to provide highly professional renal ultrasound examinations also for patients hospitalized in other Wards. Moreover, a certain amount of organization and secretarial activity is necessary, with a full-time or part-time staff, depending on the workload, especially when external services are provided. Another situation is that of Medium-sized Operating Units in Nephrology (e.g., 10 beds, average dialysis and outpatient activity, etc.) Even in this case, in my opinion, the standard should provide for a Renal Ultrasonography Unit, but with a more agile structure. It should have appropriate rooming with ultrasound sets capable of executing at least bi dimensional tests. The Nephrologist in charge of this section could devote himself to this activity part-time and, in any case, he should promote the diffusion of both the theoretical and practical knowledge of ultrasound to the majority of the medical staff. Color-Doppler examinations could be performed indifferently by the Ultrasonography Unit itself (if it has the appropriate instrument) or by another qualified Unit. At last, the Dialysis Operating Units. In this case, the nephrologist can refer ultrasound examinations to another Operating Unit or run the ultrasound activity with other Operating Units. Let us now go to the second point : Quality instruments in renal Ultrasonography The ones that I chose, on the basis of my experience, are pointed out in List 1

1. “Know how” is essential to furnish quality services. The vocational training of an ultrasound technician-nephrologist is of obvious importance for Renal Ultrasound Units. Training, though, cannot be the result of sole individual initiative and good will, so that educative institutions, such as scientific associations and postgraduate schools, play an important role. As I mentioned before, Ultrasonography has not yet entered the formative curriculum of the nephrologist, nor are there Ultrasonography courses for nephrologists in postgraduate schools. Moreover, even in the United States, some Universities have begun to experimentally include Ultrasonography in Nephrology Programs. For this reason, in my opinion, ultrasound training should be added to the post-graduate Nephrology programs with the support of our Society and, moreover, we must seriously pave the way to accredit the examination. A brief comment on Ultrasonography courses, that are also a useful instrument in the formative route of the ultrasound technician: in Italy, practical Ultrasound courses are increasing, but they often are not practical at all, except for the expensive enrolment fees. It can be expected that a nephrologist-ultrasound technician participate in a carefully chosen Conference, Course or, even better, a superior level training program at least once a year. Ultrasound Web Sites for medical updating should be sought for with critical interest because of their variable quality, especially those run by United States Universities and by some Scientific Associations. The Study Group on Renal Ultrasonography of the Italian Society of Nephrology has web space inside the SIN site (www.sin-italia.org).

2. The quality of an Echographic Unit also increases through the planning of interaction with other colleagues specialized in other fields also engaged in imaging, such as urologists and radiologists. The presence of “Open Meetings” of imaging in the activity programs of the Nephrology Units is another quality instrument in Nephrology.

3. Another fundamental instrument, in my opinion, is the internal verification of the quality of the tests carried out. In other words, the check that diagnostic hypotheses made by Ultrasonography have been confirmed by other imaging techniques. For instance, the confirmation of a diagnosis of renal artery stenosis by Echo-color-Doppler or of renal vein obstruction by angiography. This involves a systematical revision of the cases examined in specific “audits”, in which the results of clinical activity are presented in terms of sensitivity, specificity and positive and negative predictive power.

4. Another quality factor, this time referred to technology, is the range of ultrasound services delivered . If we have a good ultrasound set, it is our duty to exploit its potentiality. For instance, an echo-color-Doppler set allows the exploration of neck vessels, too. For the nephrologist, the exploration of the carotid is an important factor to evaluate cardiovascular damage in uraemic patients and it would, therefore, be useful to become familiar with this measurement, too. Conclusion Nephrology and, more generally, medicine have arrived at “redde rationem” by now: the resources grow thin and the sanitary requests are spreading. I think that it is the nephrologists’ duty to optimize services with a well-timed and valid use of the techniques that lead to diagnosis and treatment. It is beyond doubt that, for this reason, Ultrasonography must enter in the nephrologist’s powers. Each of us must, however, be aware that “power” must not represent a status symbol, but it must be an instrument to “do”. We must, therefore be open-minded and highly flexible to adapt ourselves to the type and quantity of services requested with great variety in our country.

Giuseppe Curatola

Divisione di Nefrologia

Ospedali Riuniti di Reggio Calabria