<International Circulation>: You mentioned the many disciplines that are involved in the ASH organization and as metabolic disease evolves and is studied， it is becoming evident that no one disease stands alone; that they are inter-related. One of those inter-relations is that kidney disease is being considered as a coronary heart disease equivalent. What is your opinion about that?

　　Prof. Bakris:  There are actually three very well done meta-analyses， each involving more than a million people， that clearly support the notion that the presence of kidney disease (defined as people with an estimated GFR <60) independent of diabetes and independent of hypertension， that that is an independent stand-alone risk factor for cardiovascular death. Is it a CHD equivalent? In fact， the answer is no – it’s worse. There is a paper by Marcello Tonelli from Canada published in the Lancet in September last year， which was the first of three large meta-analyses. The specific question posed there was in patients with diabetes is having kidney disease an MI equivalent? His analysis showed that although it wasn’t an MI equivalent， it was actually worse than having an MI for all-cause mortality. If you had diabetes and kidney disease， that was even worse， but the presence of kidney disease was actually worse than having had a heart attack in terms of dying from all-cause mortality. If you had had a previous heart attack and if you had kidney disease， it was not the same as having had a heart attack. The other two analyses did not specifically look at death. The question was: if you had kidney disease and diabetes or if you had kidney disease and hypertension， what is contributing to what? Does the kidney disease play a role? And once again， in each of these analyses， each looking at well over a million people， they both showed that whether you had diabetes or whether you had hypertension， if you have kidney disease and your GFR is <60， that is an independent risk factor for dying not only from all-cause mortality but also cardiovascular mortality. Definitely， if you look at that overall， you can’t really say its an MI equivalent but I think you have to say that it is an independent risk factor for cardiovascular mortality and that is independent of diabetes and independent of hypertension. In my book， that is actually stronger than the CHD equivalent.

 

 

　　<International Circulation>:  Could you tell us about the significance and importance of the NUCC taxonomy code?

　　Prof. Bakris:  This is very important. A lot of people don’t understand what taxonomy codes are or do. It turns out that there is a process (like most things in life that has anything to do with the government or anything to do with lawyers) whereby before you can get a ICD-9 code you have to document the importance of having a billing code and not only that， but the general use of the medical community by the billing code. Step one in this process is to get a taxonomy code. A taxonomy code is basically step one in validating what you have is relevant， is worth billing for and is worth getting a flavor for the utility of how many people have been billed for this. We actually took a couple of years but we have a taxonomy code for the hypertension specialist， a financial code that can be used on billing slips. Will it go to Medicare for payment? No. But these taxonomy codes are recorded and the more these are used， the stronger the argument is when you go to petition for an ICD code. This will be the evidence that it is not only you using this， but also the whole community is using it and it is being used in an appropriate way. As an analogy， it’s a bit like should we give you an office in our office building. Even though you are working for us， we don’t have the space， so what makes you think you deserve an office. We will give you a mailbox. The taxonomy code is the mailbox. If I see that your mailbox is jammed daily with mail， after a span of three or four months， the conclusion will have to be reached that something is going on here and this guy needs to be here and we need to get him an office. Done. Same thing with the taxonomy code. The more it is used， at some point (and usually it takes about two years) the usage is used in applying to the ICD people to demonstrate that the item is not only valid but that there is a need for it out there. We have already demonstrated through our taxonomy code that hypertension specialists make a difference and that it improves morbidity. We have already demonstrated that it improves healthcare at least as far as risk assessment management. We already have experience from the states of South and North Carolina where the Blue Cross Blue Shield people actually paid a group of us to go and educate primary care physicians in the country and get them up to speed on how to manage hypertension because they saw that this would reduce their costs in the long run. The taxonomy code isn’t something that just happens on it’s own. It is something you have to petition for with data and get approved for. That is step one. Hopefully within the next year or two we will have enough data to petition for taxonomy for an ICD code.