Updates in the Management of Chronic Kidney Disease and Type 2 Diabetes - Episode 8

Measures to Improve Chronic Kidney Disease

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Key takeaways from the National Kidney Foundation’s new HEDIS and MIPS quality measures for patients with chronic kidney disease and type 2 diabetes.

Neil B. Minkoff, MD: If I can be flippant about that for a second, it sounds like you’re advocating that primary care physicians treat the whole patient. One of the things that has probably helped in quality of care and care coordination is the rise of the quality metric, so the percentage of patients who have an A1C [glycated hemoglobin] test, percentage of patients who are controlled, and so on, which are the traditional diabetes measures. My understanding is that the NKF, the National Kidney Foundation, has been working with the National Quality Forum and others to develop new quality measures around this, and to use those as ways of developing new benchmarks for how we’re doing with kidney disease. I’m going to open it up to Dr Bakris. You can take a stab at starting this discussion about what somebody like me should know about these quality measures and how they might be able to affect quality of care.

George L. Bakris, MD: The National Kidney Foundation, because I’ve been peripherally involved with this, has been working on this for years. This isn’t just happening in the last year or two. This has been going on for close to a decade. We’re trying to get them to understand what Rajiv and I both said in the beginning, that you need albuminuria. You can’t just measure GFR [glomerular filtration rate] because you don’t have the whole picture of the patient, from a renal or cardiovascular standpoint, but from a renal standpoint. And they thought, “What’s the point in measuring it? You’re supposed to measure it by guidelines once a year.”

When I talk to primary care doctors, they basically say, “What am I going to do with it? They’re already on an ACE [angiotensin-converting enzyme inhibitor], so we’re done.” Now we have very good data to suggest that if they have it and you can reduce it, it’s a big deal, and being on an ACE isn’t good enough. We have other treatments that can do this. But more importantly, at least the primary care doctors tell me, that it’s on their report card. Gene, you can say more about this. So if you haven’t done it, it’s a negative mark against you. Now you have to do it and address it, and it’s something that will motivate them, good or bad.

Neil B. Minkoff, MD: I’m not trying to be difficult. I have a question about it, though. We’ve already had quality measures around measuring A1C, the percentage of patients controlled in A1C, percentage of patients whose hypertension is controlled, etc. I’m not trying to be difficult, I’m trying to understand how this builds on that to provide that next level of care.

George L. Bakris, MD: Albuminuria was not part of this until recently, so that’s another dimension that they have to do and address. The hope is with the education—a lot of it we’re talking about right now—they’ll be able to be more focused on the proper things to do. Not that this is new, but it’s to refocus them on proper things to do to slow kidney disease progression. I like the British approach. The British approach is they pay you assuming you’re going to do it, then they come back and audit you. “You didn’t do it? You owe us X amount of money.” That will work. That’s my 2 cents.

Eugene Wright Jr., MD: I’d like to pick up on that. There are 2 points that I’d like to make that have some value from a primary care and patient perspective. One is that the value of what you do has to be greater than the burden to do it. Another way of saying that is it has to be easier to do the right thing than not. One of the things that we learned in patient safety officer’s school at the IHI [Institute for Healthcare Improvement] is that systems that are designed on your memory are inherently flawed because they will fail. We need to hardwire these things in.

We have very powerful tools in our EHR [electronic health record] for recognition of people who are at risk, and then for whether they’re meeting certain process measures. We gather that data for report cards, but that should prospectively go to the clinician at the time of the visit, so when I see the patient, my EHR tells me the patient is at risk for this, their stage based on their…, or what’s missing, and some recommended interventions. That’s making it easier to do the right thing than having to remember all these pathways.

Transcript edited for clarity.