a perspective on ckd management mony fraer may 2014
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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
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