Episode 20: What's Next for NxStage with Joe Turk
Last year in the U.S., home dialysis reached 14% of all treatments by Fresenius Kidney Care, and home hemodialysis with the NxStage system grew at an incredible 37%. Joe Turk, former president of NxStage Medical and current president of home and critical care therapies for Fresenius Medical Care North America, provides an inside look at how FMCNA’s merger with NxStage Medical is helping evolve and grow technology for home dialysis and critical care.

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BRAD PUFFER: Welcome everyone to this episode of Field Notes, I’m Brad Puffer on the Medical Office Communications team at Fresenius Medical Care North America and your host for this discussion today. Here we interview the experts, physicians and caregivers who bring experience, compassion, and insight into the work we do every day. We're excited to be joined today for an inside look into how the merger two years ago with NxStage Medical is helping evolve and grow technologies for home dialysis and critical care in significant ways. Just last year in the United States, home dialysis reached 14% of all treatments by Fresenius Kidney Care and home hemodialysis with the NxStage system grew at an incredible 37%. Whether it's expanding home dialysis, supporting patients with acute kidney injury due to COVID, or coming to the rescue during natural disasters the NxStage team has had a major impact. We're excited to welcome Joe Turk to look back over the past two years and then ahead to the future. Here Joe is the former president of NxStage and now the President of Home and Critical Care Therapies for Fresenius Medical Care North America. Joe, welcome to Fieldnotes.

JOE TURK: Hey Brad, it's good to be here. Thanks for inviting me.

BRAD PUFFER: Well, I wanted to start with your thoughts when you were back at NxStage Medical helping build the company from the ground up. Could you have ever imagined being part of Fresenius Medical Care and what have been your biggest surprises since the two companies came together?

JOE TURK: It depends on whether you are in the moment or in your heart, or thinking about it in your head.

From a “in the moment perspective,” we were so laser focused on trying to build a business to try to bring new technologies and new therapies to patients at home and in the hospital that we didn't have a whole lot of time to be thinking about that we really had something to prove. And you know, every day was really focusing on that mission when you step back and thought about it. So getting in the “from ahead perspective,” the combination of NxStage and Fresenius Medical Care, it was so logical, we were complimentary. You know, NxStage was strong in home hemo products and critical care. Fresenius is strong in in-center products and PD and services. And when we thought about it, we knew that it would be a perfect match of skills. The biggest surprise I'd say when NxStage and Fresenius merged and first came together was the incredible alignment in in mission and philosophy, which was pretty amazing, given how different the companies were in size, and you know, maturity and everything else.

BRAD PUFFER: When you look back over those two years, what would you say are the two or three things you're most proud of?

JOE TURK: The first is the rapid and continued acceleration of home dialysis trainings you mentioned in your intro. So many more folks are actually realizing the benefit of home hemodialysis therapy and that accelerated from minute one. The second is how we've been able to advance some of the tools and techniques that will really allow Fresenius Medical Care North America to take home to the next level. Items like the TCU. How we think about staffing connected health and telemedicine. And then thirdly, you know more recently, I'm really, really proud of how we as an organization were able to respond to the pandemic, to help both patients in the ICUs across the country, but also help patients at home.

BRAD PUFFER: Let's dig into each of those just a little bit more. We talked about the high growth rate for home hemodialysis in my introduction - did that rate of growth exceed your expectations? What do you think is causing it?

JOE TURK: We were always optimistic for the potential for home hemodialysis. You know, we'd seen over the years, and patients repeatedly told us how much it changes lives, and we knew out there that there are markets with high home adoption and others with really low home adoption. So there was clearly room to grow across the board. On one hand, we always believed that it was possible. Still, when the time came it was all new and it took all hands on decks to accomplish the growth. Education from the Medical Office and the Clinical Education teams, training activity out in the clinics from the Direct Patient Care staff, tons of manufacturing and supply chain work to support the demand, and technical support and customer service to make sure that the rapidly increasing number of patients had some place to go. I'm really proud of what the team accomplished, and I think how quickly the growth came and how significant it was, surprised us all in a good way. And I think the biggest driver was clear alignment from the very start that that growth was possible. It's the right thing to do for patients and we're going to make it a priority. The NxStage merger was a good catalyst to really emphasize that, and then with the things we've seen over the last couple of years with the changes in government programs like the ETC program and the voluntary CKCC models as well as the competition that we're seeing in the new technologies will continue to emphasize and drive the growth.

BRAD PUFFER: Well, I wanted to also talk a little more about the pandemic. Clearly a lot of work has gone into responding to all sorts of issues that we probably never predicted. You mentioned the role NxStage played specifically. How did NxStage in your team play a role and why was the NxStage system such a great option for hospitals?

JOE TURK: I'll start with the second part of that question on why the system was such a great option. One of the things that is nice about the NxStage system in the hospital is that it's so flexible in terms of being portable and deployable in different parts of the hospital. The fact that it uses bag fluids and the fact that it has the ability to deliver a wide range of therapies, whether it be a shorter therapies or more continuous CRT type therapies in the hospital - this flexibility makes it a great option. So back when the pandemic hit, one of the things that, in particularly in the first areas that it hit, it was clear that there were way more needy patients and demand for therapy than equipment and staff in the way that the treatments in the hospitals were traditionally administered. Our team was really on this from the start. We needed to understand where the real hotspots were and made sure that we were able to get the machines and the supplies to those hospitals because there were more patients than anyone had ever seen before. In these situations, we needed to be able to help create capacity. We were able to do this by training hospitals on different ways to use the machines so that more treatments could be delivered with an existing capacity of machines. We were able to help hospitals find different ways to use the different products that we have and we were able to support the hospitals leveraging the capacity that we had. In the supply chain, given our presence in the home market as well, the team was also really able to collaborate with the FKC team and the inpatient services team to really get staffing to the right place, and be able to support some of the hospitals particular in the early waves, and in New York City, with staffing. And then, we were also able to create the National Renal Intensive Care Reserve so that as these hot spots moved from place to place in the country, we could rapidly get to these hospitals, the machines, and the supplies they needed to administer the treatment. So I was really proud of how the team identified and reacted quickly, and this was something that was across the Fresenius Medical Care Organization. So it was not just NxStage, it was Fresenius inpatient services group, it was the medical office, it was manufacturing – everybody had to really coordinated in order to support this, and I feel very proud of what the team did in order to get through in those months. And the feedback that we got from some of our physician partners and customers was really tremendous.

BRAD PUFFER: Absolutely, a huge response by everybody involved. I wanted to turn now to the operational things you mentioned. I know you've been directly involved in helping the company improve its connected health platforms, for example, and new initiatives like transitional care units that are helping more patients be exposed to home and make that choice. What are the most important new initiatives that have taken off these past couple years?

JOE TURK: Connected Health is hugely important. One of the things with home is obviously the patient is doing his or her treatments at home, doesn't see the staff, you know three times a week as with in-center dialysis, and connected health is hugely important in making it easier for the staff and patient to communicate. It allows for improvement of care, whether it be through fluid management or better communication of training items, that regular communication, and the ability to follow up really allows for improvement of care. And right now, the vast majority of patients, both on hemodialysis and on peritoneal dialysis are already connected in some way. Whether it be with Next To Me or TheHub, or just starting with PD with Conexus and overtime, we're going to continuously improve the functionality to just make it better. And better for patients and staff so connected health is a big effort that will continue to progress in the coming years. And the other one you mentioned - transitional care units really has the potential to be a game changer. As many of us have discussed before, half of patients that start dialysis start on an unplanned basis. So while it would be great for everybody to have plenty of time to have education and choose the modalities up front before the patient has to start dialysis, that's not reality for half or more of the patients right now. So the whole transitional care unit concept, the chance to start dialysis in a simpler, more focused fashion is important. Not only to give the patient a better chance to choose home, and as we've seen over 40% of patients then go through the transitional care units, end up choosing a home modality, whether it be hemodialysis or peritoneal dialysis on a go forward basis, but the other thing that we really intend is for it to be a better start to dialysis. Give patients a better chance of getting a permanent access, a better chance to stabilize and stay out of the hospital. So we're following that very closely and the early results are very, very encouraging. So I think that connected health and transitional care units have a lot of running room to really improve patient care, so Brad these are some things we're really going to be focusing on here over in 2021 and beyond.

BRAD PUFFER: I want to get back to the NxStage system itself because that's where we began when we talked about the merger. We talked about the rapid growth in home hemodialysis with our company. We also just announced a major agreement with DaVita, the other largest service provider in the US. They are investing heavily in the NxStage system as well - that must feel really good.

JOE TURK: Definitely, Brad. NxStage has been working with DaVita for a long time and DaVita has been building their home programs as well for a long time. It's really nice to see that they're committing to home hemodialysis going forward as well as peritoneal dialysis and the NxStage product. And with both Fresenius Kidney Care and Davita working to improve and expand their home programs - that's a really good thing.

BRAD PUFFER: And it sounds like the advantages of the NxStage system compared to anything else on the market are really strong when you talk about that ability to have freedom and lifestyle choices and travel. Tell us a little bit about what makes that system so unique.

JOE TURK: We have been doing this for a long time. We started the company to really try to create a better way for patients and try to create a system that was really designed to allow for home hemodialysis to be done and be done in a simpler, more reliable fashion. And so there are a lot of things that about the NxStage system that are different. It's the only machine that's small enough to take on the road or even on a plane. We've done some research overtime and most patients, the vast majority of patients, both desire and do travel at some point during the year and really benefit from that. And NxStage is the only system that can do that overtime. We've also enhanced the machine and worked with the FDA to allow for additional indications for use, whether it be for solo dialysis without a partner or nocturnal dialysis, doing the dialysis overnight and the NxStage system is the only device that has those indications, perhaps more. Most importantly, it's the only system that can both use dialysate that's produced onsite through the pure flow device, but also can use bag dialysate when water is unavailable, and that's really important not just for travel but with emergency situations. So we were constantly working to expand and to improve the machine and make it more applicable for more different situations, but really where it starts is with its size and its portability and its ability to use bag fluid really makes it different, and nothing else is out there like that. You know the other thing that we can't discount is the tremendous development of our clinical education expertise and resources, technical support, customer supply chain and those things, are so important to supporting home patients and making sure that their experience can be good, and they can be successful at the therapies.  A lot of it is about the machine, but a lot of it is also about the support that surrounds that device, that technology, and that's why the NxStage system is so competitive on the market.

BRAD PUFFER: Yeah, that's a really good point about the support and having somebody always there to troubleshoot or deal with the supply issue, and make sure you have the supplies you need to perform dialysis. You talked about the bag dialysis situation. I wanted to expand a little bit on that because it wasn't that long ago that Texas was essentially shut down with lack of water and electricity throughout the state. And my understanding is the NxStage team really rose to that occasion, helping not just NxStage home patients and ensuring they never missed the treatment because they had that emergency supply of dialysate, but also just responding to hospitals and even in center units that needed some extra machines to keep dialyzing our patients. 

JOE TURK: The biggest challenge in dialysis is water. If you don't have water, you can't make dialysate and you can't do dialysis, and that's one of the reasons why the NxStage system is so different and is so key in situations like this. We saw on the news how severe the Texas situation was with the weather. But these sorts of things happen all the time in different ways, whether it be water main breaks or algae blooms, or different things like that. There are times across the country every month that dialysis is impacted because of the lack of availability of water. Certainly with home dialysis, the nice thing is that NxStage makes sure that home dialysis patients always have some extra supplies of both the cartridges, but also bag fluid. So in the case that some things like this happen, the patients can actually do the therapy. But we were also able to help out in some other settings both with the portability and the flexibility of the device, but also the bag fluid. And we were able to actually help out some dialysis centers that did not have ready access to water for a period of time where we were able to get machines and water in there to help. Then also the hospitals when they have programs to support dialysis patients that are in the hospital. There were a number of hospitals across Texas that NxStage was able to jump in and support, and make sure that they could take care of the patients with our technology. So hats off again to the team and the technology-  really able to make a big difference with a number of different customers and patients.

BRAD PUFFER: I want to just kind of take a look ahead as we finish up our conversation here. What is next for the NxStage system within Fresenius Medical Care North America? How do you see home dialysis growth continuing to accelerate? And how will the team be part of that in the future?

JOE TURK: I truly believe we’re just at the start with the access that patients can have to home dialysis going forward, and that's our intent to enable that. But there are also a number of governmental programs that we mentioned before that are in place now, too, to really support that.  You know, first NxStage is going to continue to innovate to make dialysis, you know simpler, and more doable at home from for more and more patients, and that involves continuous improvements of both our interface and building upon the technology that we have and also our connected health, the Nx2me platform - the sky is really the limit in terms of what those will be able to do for patients. We’re also making some investments to change the way that we deliver dialysate overtime to make the system even more flexible. We will continue to lead in innovation as we have for the recent years in home dialysis to really make things better for patients --- Real opportunities to share best practices amongst the services side of the business, the dialysis centers in the home programs themselves. There's a lot of opportunity, both for technology to enable growth, but there's also a number of best practices that we have within our own clinics right now that we can expand and continue to grow home, and do great things for patients.

BRAD PUFFER: Well, it’ll certainly be great to see how it continues to accelerate over the next few years. This has been a great conversation Joe and thank you so much for joining us.

JOE TURK: Hey Brad, always happy to join and talk about home dialysis. I'm excited about it and it's a chance to do really fantastic thing for patients.

BRAD PUFFER : A note to our listeners. We want to remind you that the NxStage system is a prescription device, and like all medical devices, include some risks. The risks associated with hemodialysis treatments in any environment include, but are not limited to: high blood pressure, fluid overload, low blood pressure, heart related issues, and vascular access complications. Patients should also consult their doctor to understand the risks and responsibilities of performing these therapies. using NxStage system. For a full list of risks and responsibilities, including the increased risks associated with solo and nocturnal use, please visit NxStage.com, What You Need to Know, Risks and Responsibilities. Don't forget you can find Field Notes on the Apple Store or Google Play or right here at FMCNA.com, where you can also find our annual medical report and other featured articles. We hope you'll come back and join us as we have many more topics to discuss. Until next time, I'm Brad Puffer and you've been listening to Field Notes by Fresenius Medical Care. Take care, everyone.