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Risk Stratification and Care Navigation in Cardiorenal Metabolic Syndrome


Jeffrey Turner, MD, and Nihar R. Desai, MD, MPH, provide insight into the identification of high-risk patients with cardiorenal metabolic syndrome and the impact of case-management resources on patient outcomes.

Neil Minkoff, MD: When I think about this population and disease state, I’m taking a few of the diagnoses that most concern me, and I’m lumping them together. As people treating this frequently, you must have a different perspective of the value-stratify risk. Dr Turner, who are the patients you worry about? As you’re seeing a patient, what are you looking for in terms of outcomes, comorbidities, or even tendencies in practice to determine who are at risk for the worst outcomes?

Jeffrey Turner, MD: What drives the prognosis in these patients is their cardiovascular disease. For most, we’re talking about heart failure, so the ones I worry about most are the ones with the most advanced heart failure. Those are often patients who are very difficult to get their volume under control, so they don’t respond to diuretics well—or they respond but to very high doses. Their blood pressure control can be very difficult. They lack stability, so they need constant monitoring and adjustment of medications.

There’s been an evolution with cardiorenal metabolic syndrome for nephrologists. Data has shown that kidney numbers and the day-to-day changes in creatinine aren’t the most important metrics to look at. Looking at their volume management and their heart failure and cardiovascular state is what drives the prognosis of these patients. That’s what I look at first and foremost, and what concerns me the most is how well they’re doing from that standpoint.

Neil Minkoff, MD: You’re in an institution that provides case-management, or care-navigation, services to help these patients navigate through the system. Do you see a difference between the level of support that these patients might be getting from a payer or a Medicare Advantage-type program that tend to have a great deal of care management or case management versus what you’re able to do internally? Are any of the external programs helpful to you?

Jeffrey Turner, MD: I have a hard time assessing my experience with those different programs. I’m inclined to believe that they’re helpful—this gets back to looking at the outcomes for a specific patient—but from my vantage point, I’m not sitting there looking at my patient panel and seeing who’s part of a chronic disease management program and what their outcomes are. My general gestalt when I think about my patient is that these [programs] are very beneficial.

Neil Minkoff, MD: Does anybody else have experience with external or internal case-management programs?

Nihar R. Desai, MD, MPH: All of us have said through discussion that for too many of us—cardiologists, endocrinologists, and nephrologists are probably all guilty of this to some degree…There’s a very “organ-centric for disease-specific” mentality. We have to abandon that and move to a patient-centric view of the world. These patients are the definition of what a multidisciplinary team is all about because if you’ve got cardiac disease, renal disease, metabolic syndrome, or diabetes—for many of our patients, all those things—then what you need is not just 1 person who’s thinking about this part of your body while another person is thinking about another part of your body. [You need] someone who’s thinking about you as a whole patient. We’ve tried exploring some novel ways of doing this through care navigators on the heart failure side and for the multimorbid patients that are in value-based care programs. It’s an area where, on the payer side, we’ve seen some great work. Some nice partnerships have evolved, especially to your point on the Medicare Advantage side and some of the other risk-bearing contracts we have. There’s a sense of collaboration between the payers and health system and providers concerning a very challenging set of patients that have high need, high touch, high utilization that could cost drivers. Care coordination and high-value therapies can go a long way toward better outcomes, lower costs, and better value.

Transcript edited for clarity.

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