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Continued Health Disparities Seen in Practice


Drs Feldman, Pitt, and Agarwal describe the common CKD health disparities seen at their institutions and the steps they have taken to address them.

Ryan Haumschild, PharmD, MS, MBA: Lastly, I want us to talk about the future of CKD [chronic kidney disease] management. We talked about innovative therapies, focusing on disparities of care and how we can make an impact. I want to explore the unmet needs and additional considerations in treatment. I’ll start with Dr Agarwal. What health disparities has your institution identified with patients with CKD? What steps are you or your institution doing to address these health disparities? What can be done to improve outcomes in this patient population?

Rajiv Agarwal, MD, MS: Great question, Ryan. One key issue is education. As a society, blood pressure and cholesterol are in common parlance. CKD draws a blank. If you were to stand in Times Square and ask somebody, “What does CKD mean to you?” I don’t think many people would [know] what it stands for. We have to raise awareness of chronic kidney disease. The National Kidney Foundation has done a fabulous job, but we have to get out the message that chronic kidney disease is real and silent, and there’s something that can be done about it because we aren’t in the 1990s or 2000s anymore. We now have treatments that can help.

Educating physicians is important. I hate the word providers because I didn’t go to provider school. I’m not a provider, I’m a physician. Education of my colleagues is important because my colleagues in primary care are overwhelmed with information from so many fields. If they aren’t educated about advances with the motive to make a difference in their patients’ lives, how can they do it? Paul said a very important word: why. Why should I know it? If your common theme is to make a difference in your patients’ lives, then this is the reason you need to know it. What’s the minimum information I need to know? That’s what we need to provide in terms of education. People say, “This too simple.” I say, “Make it third-grade level [so that] everybody gets it. Don’t make it PhD level, because nobody will understand.” What stays with them is what they can act on.

The second issue is prevention. In the past, we always looked at treatment. Now it’s prevention. We now have agents that can prevent the onset of cardiovascular disease and kidney disease progression. But the most important [part] is access. If I don’t have the ability to prescribe the approved drugs, how can I make a difference? If the patients can’t afford these drugs that might be able to work, how am I going to make a difference? That will need everybody at the table—patients, physicians, payers, the government, researchers—to come together and say, “We aren’t doing research to build ivory towers. We’re doing it to make a difference in the lives of our patients.” If you can’t prescribe and make a difference in patients’ lives, then research isn’t worth anything. I’ll close there.

Ryan Haumschild, PharmD, MS, MBA: Excellent. Thank you for that. Dr Feldman, how about you? At your institution, what are some of the specific strategies you’re using to focus on health disparities with patients with CKD? What are the next steps to improve the overall population health?

Jeffrey Feldman, MD: For the past many years, using diabetes as the stepping stone, we have had a work group across our hospital working with primary care. We meet once a month. All high-risk patients are sent for CKD [testing] if they have diabetes. One issue we’re looking at is disparities of care. The other issue, as Dr Agarwal correctly stated, is implementation of this science in getting the patients the medications, which is very difficult and requires a team. Basically, we’ve been using a team, our medical assistants. I’m fortunate to have 3 good [medical assistants] focused on patient care, putting the patient at the center, taking questions and calls about the medications, and trying to get them assistance to get them all the resources that help people and prevent progression of diseases, as we’ve talked about over the last hour and a half or so.

Ryan Haumschild, PharmD, MS, MBA: Dr Pitt, how do you and your institution focus on health disparities here?

Bertram Pitt, MD: A lot of the points have already been made, but guidelines have failed us in many ways, and people don’t follow them. There’s an opportunity. We talked about the tools we have, but we need to have further studies to prove their cost-effectiveness and utility. There’s a lot of opportunity to move these tools into prevention and stop before—Dr Feldman talked about end-stage renal disease, but we have to go much earlier in hypertension and the risk factors and prevent the development of CKD and heart failure. If we wait until we have it, the game is up. It’s too costly. We need our friends in family practice and internists to do this. Education is important, but education alone probably won’t do it. We need to have incentives. I’m sure our friends at Humana are thinking about all these things. Given the tools we have, there’s a tremendous opportunity to change the game.

Ryan Haumschild, PharmD, MS, MBA: Paul, from your perspective, with payers, payer pathways, and the different issues going on, [are there] any specific initiatives that you’re focused on with health disparities in CKD?

Paul Sapia, MHA: Yes. That’s a great question. Everybody has touched on it. We touched on it earlier, starting to look at behavior change and the health-related social needs that members are experiencing within [their] community. One thing that we haven’t talked about is looking at the influential people within a community, such as pastors, faith leaders, senior services people, teachers, and principals, to help us tell the story about why behavior change is important and why we can do those types of things.

Then [we want to] connect people to those resources within communities. We have tons of safety net providers, free services, and other things that are available to people, but they don’t [know] what’s available for them. [It’s important to] connect those resources to the clinicians and medical professionals who are helping to address those members. That’s a big key point. We have to start to explain why and get the people who can tell the story for us to help create behavior change. We have too many people seeking care at the emergency department who don’t have a medical home. How do we get people to think differently about a primary care physician as a gatekeeper to help them navigate the health system and the resources available to them? That’s one thing that we’ve done with a bold goal in our social determinants of health drive within Humana.

Transcript edited for clarity.

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