Nephrologist Spotlight on Luis Alvarez, MD, PhD: Catalyzing System Change in ESRD Care
With a career dedicated to transforming dialysis care, Alvarez discusses trends, challenges, and opportunities, and how Tablo addresses the key to meaningful change: meeting patients where they are.
Luis Alvarez, MD, PhD is a problem solver who is focused on an ambitious goal: driving change in today’s outdated and costly end-stage renal disease (ESRD) care model in a way that provides the clinical benefits that society, and patients, need and want. For Alvarez, the roadmap to system improvement is now being paved by reimbursement incentives aligning to drive innovative new models in dialysis care, and better patient outcomes—in-hospital, in-center, and at home. And, the signs along this road are directing healthcare providers to, in Alvarez’s words, “meet the patient where they are.”
“It’s a very exciting time to be in this space, and a very exciting time to be able to use a next-generation instrument like the Tablo Hemodialysis System to show that meaningful change is indeed possible,” says Alvarez.
A nephrologist, researcher, medical device developer, and current attending physician at Stanford University Hospital, Alvarez now serves as the Chair of Nephrology at Sutter Health – Palo Alto Medical Foundation (PAMF), where his work includes treating patients on Tablo across the continuum of care. He is also Outset Medical’s Chief Technology and Innovation Advisor, medical director at Satellite WellBound in Fremont, CA, and a board member at Satellite Healthcare.
“There is tremendous opportunity for improvement in ESRD care in general,” he says. “In my research I’m looking to answer the question of how can we use medical devices like Tablo to drive an overall care elevation across the kidney disease and dialysis space, and provide better care at a more affordable price point for patients—within integrated healthcare systems and into broader, more creative settings of care.
“Dialysis Factory” Model vs. a Better Future
Alvarez notes that the for-profit, in-center dialysis care model of today is, in his and other experts’ opinion, largely unsustainable—although enormous resources have gone into protecting the institutions that have turned ESRD care in the U.S. into big business. A new, more empowering model for the future is blossoming and gathering momentum, and it will look quite different than dialysis care today, which hasn’t changed much over the decades.
“The great challenge, and opportunity, is in disrupting the outmoded ‘megaclinic’ model of care, focused on the efficiency of the provider, to understanding that it no longer provides the type of clinical benefits that we as a society, and that of our patients, deserve and want,” he says. “The focus needs to be on the patient. There’s everything from feeling better, to avoiding congestive heart failure hospitalizations, to decreasing infection rates including vascular access and COVID-19. We know that patients do better in different environments than the current in-center ‘dialysis factory’ that it has become.”
“The ‘True North’ is, meet the patients where they’re at. If patients are performing in-center self-care, or if they are at home, that’s where we meet them.”
Beyond patient outcomes, the exorbitant cost of status-quo dialysis care in this growing population is unsustainable in the long run, in Alvarez’s view. “As a nation, we have realized that we’re spending an awful lot of money on what could be better care, and I’m not going to say it’s bad care, I’m just saying it could be better care,” he says. “On the positive side, this realization is helping to incentivize long-needed options such as home dialysis,” Alvarez notes, “but that creativity and open-mindedness will be needed to get to that goal.”
“As a nation, we’re ready for it, the economic incentives are there for it. Patients are ready for it, physicians are ready for it,” he says. “And, momentum for this much-needed transformation, fueled by medical device innovation, is already in play.”
Meet Patients Where They Are
Alvarez notes that as a nephrologist, when his patients are able to manage their own dialysis treatments at home, they do much better. “Many of them really thrive on being able to take care of themselves … there are many patients like that, and that’s the fun part,” he says. “The ‘True North’ is, meet the patients where they’re at. If patients are performing in-center self-care, or if they are at home, that’s where we meet them.” (Both options are included in the CMS ESRD Treatment Choices [ETC] Model, that is intended, in part, to incentivize home dialysis, reduce Medicare expenditures, and preserve or enhance ESRD patient quality of care.)
In fact, Alvarez notes that in studies and surveys of nephrologists, “they all indicate that if they themselves had to do dialysis, they would choose home-based therapy.”
“There’s a world where patients really can start dialysis and manage all of their therapy, from start to finish, in their home. I think that’s a very exciting opportunity. We have an opportunity as a field to really engage patients in a completely different way than we have, and to create an environment of empowerment. I think companies like Outset with the Tablo system play a really important role in creating that engagement, and the opportunity for that engagement.”
Alvarez also notes that there is a huge opportunity to start the path to home dialysis when a patient is stabilized in the hospital. “I think that there’s an opportunity to show patients how they can be empowered to take care of themselves, until such time as they get a transplant, and have that opportunity to learn those skills while in the hospital—a ‘home first’ mindset, if you will. It then becomes a seamless bridge to the outpatient and home experience,” he says.
In his view, the centralization of healthcare in America into powerful integrated delivery networks (IDNs), with a focus on better outcomes, lower costs, and incentives to move the dialysis model out of the hospital setting—including the use of transitional care units (TCUs)—is helping to drive care home. “I think that Tablo is a very important and trailblazing opportunity for those who want to improve patient care, to do that.”
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Rethinking Transitional Care
Alvarez offers some outside-the-box thinking about what transitional care units are today—where dialysis patients are empowered to do their own treatment, with healthcare provider assistance in a hospital or in-center setting—and what they could be. “I think people look at transitional care within the framework of the current expensive bricks-and-mortar investment in the U.S. And so, we have been focused on fitting transitional care into an existing in-center dialysis unit, and how do we create a hybrid model. But that’s really just because we’re trying to utilize the space that we have. There’s no fundamental reason that that experience has to take place within the walls of a traditional hemodialysis unit,” he says.
Alvarez envisions a future where a growing population of dialysis patients can have greater social support and receive the type of transitional care that they really need, in meeting them where they are, and at the same time eliminating the infrastructure hurdle. “There’s lots of places, whether it’s the hotel down the street, a strip mall, a social club, or a parks and rec center. Importantly, the decoupling of water treatment from the actual dialysis performance in Tablo, is really key to reinventing and re-imagining that model of care delivery.”
Alvarez has an archive of clinical papers pointing to other ways in which the capabilities of Tablo support ESRD system change, briefly mentioned below.
Research Highlights the Role of Tablo in Catalyzing Change
Dr. Alvarez and his team at PAMF, along with other clinical investigators from around the US and Canada, have published numerous studies addressing some of the most daunting challenges in dialysis, and how technology built into Tablo is helping to overcome barriers and enable meaningful change in this space. Study topics have included blood pressure stability, dialysate flow rates, urea clearance (the latter two among other Outset Medical evidence supporting the use of 300 mL/min flow rates in achieving clearance targets), and prolonged intermittent renal replacement therapy (PIRRT; also known as SLED) treatment as a lower-cost option than both CRRT and IHD, among others.
Alvarez is also keenly interested in showing how the system’s innovative technology is helping to overcome barriers to patients dialyzing at home. Positive results have been noted in research co-authored by Alvarez on topics ranging from the Investigational Device Exemption study that supported Outset Medical’s FDA approval for home use of Tablo, patient self-care training, home dialysis patient-reported outcomes, and barriers to home-based and self-care in-center hemodialysis. (For more information, see the Outset Medical Clinical Evidence page.)
“He Who Saves One Life, Saves the World Entire”
For Alvarez, the quote above from the Talmud summarizes a key theme in shifting the paradigm in ESRD care. “At the end of the day, it’s finding those people who really want to make the lives of patients better, and are willing to fight system change to accomplish this. Those people, and enabling those people, and partnering with those people, will be the first domino and others will follow. That’s what will drive real change,” he says.
It also comes down to what has made the most meaningful impact on him as a nephrologist: helping patients and their families through a difficult time. “I love to see patients overcome those obstacles, feel better, and re-own their life. I think about my patients who have really struggled, and thanks to forward-thinking innovations like Tablo are now out there doing things like playing golf, building businesses, and experiencing the joy of seeing new grandkids. Although we still have a long way to go, one at a time, these types of relationships are transforming ESRD care in America.”
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