Prescribing Gaps Persist in CKM Care Even as Therapies Multiply

During a recent Institute for Value-Based Medicine^® event, clinicians and population health leaders at University Hospitals (UH) in Cleveland, Ohio, described a widening distance between what guidelines now recommend for cardiovascular-kidney-metabolic (CKM) syndrome and what patients actually receive. The event was hosted on June 11, 2026, by The American Journal of Managed Care in partnership with the UH Harrington Heart & Vascular Institute and UH Center for Integrated and Novel Approaches in Vascular-Metabolic Disease (CINEMA).

The meeting convened 2 days after the first multisociety CKM guideline was published simultaneously in the Journal of the American College of Cardiology and Circulation. The guideline names an interdisciplinary CKM model of care as a Class 1 recommendation.¹

Valerie M. Reese, MBA, MEd, vice president of population health at University Hospitals, opened the program by challenging attendees to dismantle silos. Cardiovascular disease, chronic kidney disease (CKD), diabetes, and obesity “are not isolated challenges; they are interconnected conditions,” she said, describing a systems-of-care approach that aligns specialty care, primary care, care management, and behavioral health around at-risk patients.

Kidney Disease Sits at the Center of CKM Syndrome

Keynote speaker Katherine R. Tuttle, MD, FASN, FACP, FNKF, executive director for research at Providence Health Care and professor of medicine at the University of Washington, placed CKD at the center of CKM syndrome. Patients with stage III or IV CKD have a cardiovascular risk equivalent to that of subclinical atherosclerotic disease, she said, and 4 of 10 people with diabetes will develop kidney disease.

Therapies have converged, Tuttle said, moving from a sequential pyramid to what her guideline group now calls a windmill: concurrent initiation of renin-angiotensin system inhibitors, sodium-glucose cotransporter 2 (SGLT2) inhibitors, nonsteroidal mineralocorticoid receptor antagonists (MRAs), and glucagon-like peptide-1 (GLP-1) receptor agonists. Modeling data suggests that the combination could cut kidney failure events by more than half and all-cause mortality by approximately one-third. However, uptake tells a different story. In the Center for Kidney Disease Research, Education, and Hope registry data through 2024, overall use of MRAs remained below 1%, while the use of SGLT2 inhibitors and GLP-1 receptor agonists was slowly approaching 20%.

Asked by event cochair Ian J. Neeland, MD, FAHA, FACC, what single lever would move implementation, Tuttle pointed to policy. “What gets paid for and what gets measured is what gets done,” Tuttle said, noting the
drop in heart failure readmissions that followed
financial incentives.

CINEMA Model Earns Class 1 Recommendation

Neeland, director of cardiovascular prevention and director of UH CINEMA at UH Harrington Heart & Vascular Institute, noted that it is one of the first dedicated CKM clinics in the US. CINEMA visits last an hour or longer and pair patients with a dietitian, nurse navigator, pharmacist, and clinician. Patients are supported by virtual education, exercise classes, grocery store tours, and health coaching.

Two-year results showed improvements in weight, blood pressure, glycemic, and lipid measures, along with increased use of guideline-directed therapies. In addition, the albuminuria profile of patients with CKD improved measurably.

“Moving people from one risk area to a lower risk area within several months through aggressive care can be done,” Neeland said.

He called the guideline’s endorsement of the CKM care model “the biggest win,” while acknowledging that scaling it nationally “remains a big challenge.” He also urged attention to underrecognized components of CKM, including lipoprotein(a) screening, statin intolerance alternatives,
and metabolic dysfunction–associated steatotic liver
disease (MASLD).

Team Members Point to Cost, Trust, and Time

A multidisciplinary panel translated those data into daily practice. Scott Yasinow, MD, an internal medicine physician at UH, said the shift to advanced primary care models changed how clinicians feel about referrals.

“Instead of being siloed, we’re all pulling the rope in the same direction,” he said.

Matthew Nennstiel, PharmD, a clinical pharmacist at UH, described his role as translating access to commercial, Medicare, Medicaid, and out-of-pocket pathways, plus working with patient assistance and co-pay programs, so physicians are not absorbing that work in a 15-minute visit.

Kyia Mountain, DNP, APRN-CNP, NBC-HWC, a cardiometabolic research nurse practitioner at UH, works with underserved communities in Cleveland. “Our biggest barrier here is trust,” she said, adding that community health workers are essential to bridging the gap, noting that telling a patient to eat healthier means little when they can afford only 2 meals a day and lack transportation.

Elke Eaton, MEd, BSN, CDCES, RN-BC, clinical nurse coordinator at UH, noted that patients travel from as far as West Virginia for an in-person first visit, after which nurses and dietitians deliver education virtually to “meet them where they are.”

Seth Sclair, MD, assistant professor at Case Western Reserve University School of Medicine, Division of Gastroenterology and Liver Disease, and a physician at UH, estimated that two-thirds of patients in a CKM clinic have MASLD, far more than hepatology can absorb.

“We don’t have enough bandwidth to be able to provide liver specialty care to all these different patients,” he said, endorsing Fibrosis-4 Index for Liver Fibrosis scoring and elastography as primary care–level triage.

Only 1 in 4 Patients With HFrEF Leaves Fully Optimized

In previously unpublished data, Eiran Gorodeski, MD, MPH, FACC, FHFSA, medical director of the Advanced Heart Failure and Transplant Center at UH Harrington Heart & Vascular Institute, reported on 4678 patients with heart failure with reduced ejection fraction (HFrEF) discharged from 13 UH hospitals over 1 year. Twenty-three percent left on quadruple therapy, and 26% were fully optimized after adjusting for kidney function, with rates ranging from 12% to 38% across hospitals—variation not explained by glomerular filtration rate. The majority of patients discharged by general medicine teams had markedly lower rates than those discharged by cardiologists, Gorodeski said.

“The guidelines are not talking about monitoring. They’re not talking about teaching. They’re talking about introducing medications,” Gorodeski said. He also dismissed a common objection, noting that sacubitril/valsartan and dapagliflozin are now generic, so “there’s no more excuse of cost.”

Outpatient Teams Build the Handoffs

Cochair Patrick Runnels, MD, MBA, chief medical officer of the UH Veale Healthcare Transformation Institute, moderated a panel on extending that work into the ambulatory setting. Brian Zack, MD, medical director of telehealth at UH, asked why the system cannot reach 90% and called for micro decision trees hardwired into the electronic medical record. “Every time we touch them, and we don’t at least address this, we have lost an opportunity,” he said.

Michael Adornetto, DO, medical director for the UH West Region, said the initial obstacle in primary care was informational: “We need the data that say, ‘Here’s where we are and here’s where we want to be,’ and we just didn’t have that when we started.”

Michael Duffy, PharmD, BCACP, ambulatory pharmacy manager at UH, described a monthly report that flags patients with heart failure who are not on an SGLT2 inhibitor and pends a referral order for the primary care physician to sign—a workflow now generating approximately 250 to 350 heart failure referrals per month to his team.

Tuttle pressed for attention to the transition between acute and chronic care and to undefined roles. “I would like to promote the fact that we’re on a relay race,” she said. Runnels closed by reframing accountability as a shared agreement rather than a cudgel, arguing that roles get sorted “when you bring a team together to actually adjudicate that.”

Reference

1. Ndumele CE, Rodriguez F, Dixon DL, et al. 2026 AHA/ACC/ADA/ASN guideline for the prevention, detection, evaluation, and management of cardiovascular-kidney-metabolic syndrome: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2026;87(suppl 22):e1889-e2007. doi:10.1016/j.jacc.2026.03.056