A Perspective on CKD Management

Mony Fraer

May 2014

Topics

1. CKD - Model of a Chronic Disease2. Chronic disease burdens3. Multidisciplinary Care4. Patient engagement5. The UK model

• > 13 % adults with CKD• > 15 million with stage 3 CKD• Prevalence of CKD: 5% /year growth• patients are complex and at high-medical risk (risk of reduced

all-cause mortality, CVD, infection, AKI)• risk of death from CVD > progression to ESRD• CV risk reduction - management of CKD/slowing progression

CKD - Model of a Chronic Disease

Financial Burdens ad Barriers

• before starting dialysis, majority of costs are from hospitalizations (6 mo. before initiation of dialysis)

• month of initiation of dialysis: $25,000 - $35,000. • annual cost: CKD ($28,000 - $65,000 ) and ESRD ($85,000 )• annual cost: $5,000 for CHF and $10,000 for DM• Government/payers are demanding value ( = quality/cost)• reimbursement models that do not align incentives for all

involved

The Problem

Management of advanced CKD is suboptimal (irrespective of whether patients are treated by nephrologists or non-nephrologists)

Causes

• late diagnosis of CKD• lack of awareness - magnitude and significance of CKD • fragmentation of care with (multiple caregivers in myriad

settings)• late referral to nephrology• insufficient use of therapies to slow CKD progression • insufficient treatment of complications/comorbidities• abrupt transition to renal replacement therapy

Causes

• solitary physician visits - not an appropriate care model• CKD disparities (racial, ethnic, socio-economic)

ESRD patients• fragmented care• lack of attention to comorbid conditions• failure to provide preventative services

Aims

1. Early identification of CKD and its complications2. Delay/prevent progression of CKD and need for RRT:3. Management of the comorbid conditions 4. Smoothing the transition to ESRD and RRT5. Attention to avoidable hospitalizations

Nephrologists

• > 2000 CKD patients/nephrologist• usually nonprogressive disease and not necessarily requiring

specialized care• no formal involvement of the PCP beyond the traditional

communication of a clinic note

Primary Care Physicians

• limited time to deliver appropriate/recommended chronic disease mgmt. (CDM) in addition to diagnosing new problems and providing preventive care

• large number of MD’s - not aware of KDOQI guidelines

• overlap between DM, CVD and CKD, it is possible that physicians prioritize treatment for DM and CVD (link between these and CKD)

Patients as Self-managers

• Complex treatment regimens

• Monitor their conditions

• Make lifestyle changes

• Make decisions about when to seek professional care and when they can handle a problem on their own

• High level of knowledge, skill, and confidence

Education

Patient awareness, education, empowerment in decision making and repeated interactions with the care team

• dietary counseling • medication management • ongoing education about RRT/conservative care • about the condition• other behaviors

National Kidney Foundation tools: www.kidney.org

Patient Engagement

• Assessing depression

• Patient activation measures (patient knowledge, skill, and confidence for self-management)

• Medication adherence

• Self-efficacy

• Disease knowledge

https://uiowa.qualtrics.com/SE/?SID=SV_cN2Pd3PhvmktuER

Questions to Answer

1. How to leverage the expertise of nephrologists 2. At which stage of CKD should patients be referred to a nephrologist3. What is the level of expertise that can be expected of PCP’s in the mgmt. of CKD4. Best way to involve allied health professionals in multidisciplinary CKD care5. Is there a point, before ESRD, at which the nephrologistshould assume primary care of a patient with CKD

Multidisciplinary Care

Elements of a CKD model of care:• Early identification of patients • Longitudinal protocolized follow-up (as opposed to episodic

care)• Interventions to delay progression • Timely preparation for RRT/or planning for conservative care

The Team

• Nurses• PCP’s• Nephrologists• Dietitians• Cardiologists, endocrinologists, vascular surgeons, transplant

physicians• Other: physiotherapists, social workers, and psychologists

Implementation of Care Models

• data management tools• education programs (for team members)• communication tools• formalized protocols• guideline-driven approach• restructuring of practices to multidisciplinary teams• computerized decision-making support

Pharmacists

Navigator/Case manager

• changes in patient status - appropriate team members are involved at the appropriate time for specific patients.

• help the patient and their family understand where they are in the spectrum of disease

More Prominent Involvement of PCP’s

- stable kidney function/slowly progressive - issues of reversibility have been addressed- measures implemented to slow progression- comorbidities and CV risk factors have been addressed- had dietary counseling

More Prominent Involvement of PCP’s

- have made modality decisions and have a plan for the start of RRT

- on all appropriate medications - reasonable achievement of target BP- stabilization of laboratory parameters associated with CKD

The ability of the PCP to liaise with the MDC team must be effortless

Results

integrated care (comprehensive, team-based, MDC for CKD and comorbidities) vs. usual care (PCP management using outside nephrology consultation) :

- slower decline in GFR over time - lower percentage of patients initiating dialysis

Through the Looking Glass: A New Perspective on Population Management

https://www.uhc.edu/cps/rde/xchg/wwwuhc/hs.xsl/56693.htm

The UK Model

• Closed managed care system funded by the government and paid for by general taxation

• Among the lowest health care spenders of OECD• All practices are fully computerized and >97% receive lab results

electronically (will detect CKD at the primary care level)

The UK Model

• Strategic planning for kidney services (public health problem)- primary care priority

- guidelines selecting patients for referral to specialized care - quality outcomes framework system rewards physicians for

tracking specific evidence-based indicators in CKD- specialized multidisciplinary clinics

The UK Model

In the first 2 y > 40% of the expected CKD 3 to 5 population registered in primary care

Can we do it?

• Assessing depression, patient knowledge, skill, and confidence for self-management, medication adherence

• Referral charts (decision making trees) for primary care

• Multidisciplinary clinics

• Incentives (insurers, employers)

• UK type level of integration and decision making