Care Coordination for Patients With CKD and T2DM

Various types of health care professionals who may play a role in treating patients with chronic kidney disease, and recommendations to help overcome barriers that impact risk of disease progression and outcomes for patients.

Neil B. Minkoff, MD: That raises a question for me as a former primary care physician and someone who has spent some time in integrated networks trying to improve coordination of care, which is the potential disconnect between the primary care physician, nephrologist, maybe the diabetologist, and so on—because Dr Bakris said it takes a village, right? Many of these patients may have a cardiologist, a nephrologist, a primary care doctor, and so on. What are some of the challenges in trying to coordinate care across quite a wide set of things that need to be done? We’ve talked about weight loss, lipid loss, sugar control, and dietary control. There’s a lot going on here.

George L. Bakris, MD: We’ve been through the era of multidimensional practices. There’s a paradigm for this by our good friend, Mikhail Kosiborod, [MD,] who’s a cardiologist in Kansas City. He has an integrative network within the same institution of endocrinologists, cardiologists, and if needed, nephrologists, where patient X is being seen by specific individuals within each of those subspecialties, and there’s a plan that’s agreed upon by everybody. The patient is notified about it, and you move forward with that. Right now, I see the patient, primary care sees the patient, the endocrinologist sees the patient, and everybody is writing notes. You can send the notes to everybody, and then people have to read the notes, and in the meantime they’ve got other patients they’ve got to worry about. It doesn’t fit as well as doing it this way.

This model is alive and well in the United Kingdom, but in the United States, it’s novel. People are starting to do this integrative care at some level. There are given physicians who are all talking to each other. But we’re far from that as a model. The payers are working on this right now, and I would predict that they’re going to love this model, because it’s going to keep people out of the hospital, it’s going to be better communication for everybody, and the patients are going to understand what they need to do and who they need to see if there’s a specific question. That’s not necessarily true now.

Neil B. Minkoff, MD: Dr Wright, what’s your experience with primary care doctors trying to address these issues and the difficulty of coordination of care? It seems to me that a lot of this starts in the primary care office.

Eugene Wright Jr., MD: You’re right. And as I mentioned earlier, awareness is an issue. One of the things we’re starting to wrestle with in primary care is that diabetes, heart disease, and kidney disease are all interrelated. What I mean by that is improvement or deterioration in one leads to improvement or deterioration in the other. As the American Heart Association said about 20 years ago, perhaps diabetes is a cardiovascular disease manifest as dysglycemia. There may be some underlying truth in that. Maybe it’s a cardiorenal disease manifest as dysglycemia. The way we approach this in primary care has to be as a holistic system, so that we’re not just treating glucose, we’re not just treating blood pressure, we’re not just treating lipids, but we’re treating those with the idea of this whole system improvement.

In primary care, the challenge is having very clear, concise, specialty-endorsed, guideline-directed therapy. Once we can get that and can say everybody is on the same page with how we should be approaching this, that will be a big boost for us to be able to follow these.

Transcript edited for clarity.

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