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Early Intervention Impacting CKD Treatment Pathways


Clinical and financial considerations surrounding screening and early intervention for CKD are discussed by key opinion leaders.

Ryan Haumschild, PharmD, MS, MBA: When you’re thinking about this, Dr Green…how can early intervention in patients with heart failure or type 2 diabetes…prevent or slow the progression of CKD [chronic kidney disease]? And what have you really seen in your practice?

Jennifer B. Green, MD: Well, that’s a great question. Before I dive into that, can I just make a couple of comments about some of what’s been discussed already in the program? So I thank Dr Anderson for bringing up [the] idea that managing cardiorenal risk is a shared responsibility. I think management of risk is often treated as a hot potato, right? It’s kind of tossed to the next doctor that the individual is…going to see. And we need to stop and take the time to understand our patient’s risk and recommend either the interventions designed to treat ourselves or to engage the other providers directly who will be responsible for that aspect of care. And we’ve talked a lot about urine albumin-creatinine measurements. I would like to remind everyone who is listening that this is not a new recommendation. This is not a new test for people with type 2 diabetes. That has been a recommendation that they have that test performed and at least annually for decades. So this is nothing new. It’s just not happening. So we really failed to appreciate the risk posed to many of our patients with type 2 diabetes. And I’m a little bit more diabetes centric, so I will mention that a good bit of the time, but you brought up early intervention. So of course, identification of risk is part of early identification of risk and the implementation of strategies to mitigate that risk. When I think about early intervention, I think about it in 2 ways. There’s early in the sense of early in the course of the disease, but there’s also early in a person’s life span. So those are 2 different concepts. And we need to be very cognizant of the fact that in this country, people are developing type 2 diabetes or these other complications at very young ages. And there [are] very compelling data that [have] been published that show if you are a young person—and when I say young, I’m talking about 40s who has type 2 diabetes—and you have also either kidney disease or cardiovascular disease or both, the adverse effect on your life expectancy is very, very substantial. If you have these problems early in life—don’t forget about people who are young with these conditions. There’s a misconception that they are not at great risk. In fact, their risk is greatest over their lifetime, and they need to be identified as at risk and treated appropriately. So that’s an opportunity. The reason we want to think about early intervention, particularly when it comes to kidney disease and kidney function, is that, at a certain point in adulthood, your eGFR [estimated glomerular filtration rate], your kidney function just starts to steadily decline. And you can only modify that so much if you are a person who has diabetes or already has kidney disease or has heart disease. And in particular, if you have a lot of albumin in your urine, you’re on the fast track, and your eGFR decline over time will be far greater. So what we want to do is identify people early in that process where they haven’t gotten very far down that fast track toward, for example, needing dialysis, so we can intervene at that time and keep their eGFR, for example, as high as it can be for as long as it can be.

Ryan Haumschild, PharmD, MS, MBA: You know, I think we hear so much advocacy from the provider for early intervention. And I appreciate the passion because it’s the right thing to do for the patient. And so many times the question comes up: How do providers and payers incentivize early screening intervention? So, Dr Cohen, I’d like to pose that question to you and maybe [ask]: Can payers incentivize CKD screening through population health programs or maybe even internal quality measures?

Ken Cohen, MD: They can. Payers to a limited extent. I think this is more impactful when you look at our current health care landscape. We continue to have physicians who are practicing in small solo or small group practices and then many others who are practicing in more sophisticated care models where there is a population health infrastructure, where there are care managers. And we have been able to demonstrate that the quality of screening differs in those 2 models and that when patients are cared for in a sophisticated care model, they actually have higher screening rates, sometimes as much as twice as high…. And if you take that 1 step further, we’ve been able to show that when patients are cared for in models where the physician organization or the hospital physician organization is accountable for total cost of care, there is another quantum increase in outcomes. We published a study in JAMA Open Network last year, my colleagues and I, that showed, for example, there was a 10% lower rate of stroke and heart attack in Medicare patients who were treated in a 2-sided risk model compared with fee-for-service Medicare. So shifting that responsibility, both clinically and financially, to a physician organization creates a compelling indication to move upstream and begin to risk-stratify and try to get earlier into the disease process. We’ve modeled, for example, home uACR [urine albumin-creatinine ratio] programs where we send patients kits for free and have them do their screening at home, take it out of the PCPs’ [primary care physicians’] hands. Our PCPs are incredibly busy. And anything that you can do with population health management through either care management or direct patient access that will make the PCP’s burden less, it’s likely to improve ultimate screening results. We’ve even piloted doing home serum creatinine testing. We now have kits with micro capillary tubes that patients can acquire the sample on their own and just mail in and do both uACR and eGFR just through home testing. So that’s one way. The other way is to look at your population health management infrastructure and create incentives. And those incentives can either be intrinsic or extrinsic. Physicians, NPs [nurse practitioners], and PAs [physician assistants] are very competitive by nature. And transparently reporting results of screening is a very potent change agent, and nobody likes to be at the bottom of those lists. So that concept of transparent reporting is important. And on top of that, you can leverage financial incentives as well. So for clinicians who are up-to-date in screening—and it isn’t just diabetes, but creatinine clearance, uACR, breast and colorectal cancer screening, immunization rates—you can create comprehensive incentive models that encourage screening that significantly impact screening results.

Ryan Haumschild, PharmD, MS, MBA:I like that you gave us a couple of ideas focusing on value-based care, dual-sided risk with total cost of care, but even the competitiveness, I know in our organization, we like sports, but we really like competitive publishing. And so the more we can get the data out there and show the difference we’re making, I think that goes really far…. So I appreciate that perspective. And just kind of wrapping up this section, Dr Anderson, I want to pose to you: How can payers educate local providers about some of the screening guidelines and encourage them? As we heard from Dr Green, these aren’t new recommendations. These are things that have been around. How can we create more education and focus on these recommendations so that patients are screened earlier?

John E. Anderson, MD: Well, I think he said something great. You can have some incentives for financial based improvement if you’re doing the proper screening. But I think it’s also about just educating the providers in the primary care system. I mean, getting a urinalysis happens in a primary care office 10 times a day. So getting a urine sample for a uACR is not a burden. There’s no burden of acquisition. We’re pretty good at getting eGFRs, but I think for so long, the primary care community has avoided microalbumin screening because they’ve seen no value in it, and it’s a whole new day of education. So I think programs like these—any provider-based network that has incentives—I know that HEDIS [Healthcare Effectiveness Data and Information Set] is going to have incentives for getting this done. I know that some of the pathology laboratories are now wanting to do just a kidney panel, and if you order a kidney panel, you get the eGFR, the BNP [brain natriuretic peptide], and you get the uACR together. So it’s tied in a bundle. But for so long in the primary care world, we have watched our patients with chronic kidney disease get worse and worse and worse. And we’ve had nothing to offer them. If they get to the progression of CKD—because we know that most of these patients will die of a cardiovascular event before they get to end-stage kidney disease—we now have something to do, which should excite the primary care community. We have something to offer our patients we haven’t had for years. But it’s also a little bit of a stick. You need to do these, and you are going to be judged and financially rewarded based upon whether you’re doing the right thing for your patients.

Transcript is AI-generated and edited for clarity and readability.

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