Simple Workflow Fixes Can Close CKM Care Gaps, Clinicians Say

Simple operational changes are proving more effective at closing gaps in cardiovascular-kidney-metabolic (CKM) syndrome care than education campaigns alone. That was the shared conclusion of separate Population Health Roundtable discussions hosted by The American Journal of Managed Care, which convened clinicians from health systems in 2 cities this summer to examine why CKM screening and treatment remain inconsistent even after the June 2026 release of the first joint guideline on CKM syndrome from the American Heart Association, American College of Cardiology, American Diabetes Association, and American Society of Nephrology.¹

The Boston, Massachusetts, event, moderated by Muthiah Vaduganathan, MD, MPH, a cardiologist and clinical trialist at Brigham and Women’s Hospital, brought together cardiologists, endocrinologists, nephrologists, and pharmacists from Mass General Brigham, Boston Medical Center (BMC), Lahey Hospital & Medical Center, the Joslin Diabetes Center, Yale School of Medicine, Harvard Medical School, Boston University School of Medicine, The Obesity and Metabolism Institute, and Dartmouth Health. The New York, New York, event, moderated by Deepak L. Bhatt, MD, MPH, MBA, director of the Mount Sinai Fuster Heart Hospital, drew faculty from NYU Langone Health, NYU Grossman School of Medicine, and Yale School of Medicine.

Though the panels met separately, their conclusions converged on the same bottlenecks: underused screening, fragmented ownership, and administrative friction that falls hardest on patients with the fewest resources to absorb it. They identified simple changes that could have a big impact, including collecting urine samples in the clinic, shifting screening duties from physicians to medical assistants, routing specialist questions through e-consults instead of new appointments, and naming a clear owner for cases when patients cross multiple specialties.

A Screening Test That Still Isn’t Routine

Much of the discussion at both events centered on urine albumin-to-creatinine ratio (uACR) testing, a biomarker faculty said remains dramatically underused despite its established value in predicting kidney and cardiovascular outcomes.2 Sylvia Rosas, MD, MSCE, a nephrologist at the Joslin Diabetes Center in Boston, illustrated the scale of the problem by comparing it to colonoscopy preparation, where patients routinely receive a cascade of automated reminders.

“You know how many times we get that done correctly? Over 80% of the time,” she said. “But uACR for patients with hypertension and diabetes? Less than 50%.”

In New York, panelists made a similar point: Despite recent guidance, including the 2024 Kidney Disease: Improving Global Outcomes guidelines,³ uACR is still inconsistently ordered alongside estimated glomerular filtration rate.

Panelists in both cities pointed to operational fixes already improving completion rates. At BMC, primary care clinics adopted a clinic collect model in which medical assistants hand patients a specimen cup during rooming for collection in the clinic, rather than sending them to a separate lab. This change has measurably improved screening rates, according to pharmacy specialist Katelyn O’Brien, PharmD, BCPS, CDCES, BC-ADM. Rosas described a similar effort at Beth Israel Lahey Health, where medical assistants, not physicians, trigger uACR orders for patients with hypertension or type 2 diabetes.

Ralph J. Riello III, PharmD, BCPS, a clinical pharmacy specialist in cardiorenal and metabolic disorders at Yale School of Medicine, who participated in both roundtables, described building similar nudges into a decision-support trial his team is running: The system flags patients missing only a uACR result and automatically generates an order if an on-site lab is available. He also uses zip code–level data to build heat maps of undertreated populations to guide outreach and community screening.

In New York, Olugbenga G. Ogedegbe, MD, MPH, director of the Institute for Excellence in Health Equity at NYU Langone Health, framed the same category of fix in broader terms, borrowing a phrase from global health policy.

“The World Health Organization has a term for this: task-shifting,” he said. “There’s a whole policy in low-income countries where you have 1 physician to 50,000 people.… That’s how they stayed ahead of the HIV epidemic: Nurses treat HIV, not doctors.”

Streamlining Care Teams and Multipillar Therapy

Several panelists in Boston pointed to BMC’s e-consult system as a scalable way to extend specialist input without adding appointments, letting a primary care clinician or pharmacist route a question to a specialist without a
formal referral. Emily Persson, PharmD, an ambulatory clinical pharmacy specialist in cardiology at BMC, said the
model reduces confusion for patients who might
otherwise be uncertain which specialist to contact for
medication changes.

Faculty also discussed how BMC has grown its ambulatory pharmacy team to more than 60 clinical pharmacists embedded across specialties, a model O’Brien said has expanded pharmacists’ role in titrating guideline-directed therapies and managing prior authorizations, freeing physician time for diagnosis and staging.

In Boston, Riello pushed back against the common practice of maximizing one drug class before adding the next. Guideline-directed medical therapy (GDMT) for CKM syndrome rests on 4 drug classes (RAS inhibitors, sodium-glucose cotransporter 2 inhibitors, mineralocorticoid receptor antagonists, and glucagon-like peptide 1–based therapies) that together address overlapping cardiovascular, kidney, and metabolic risk.⁴

“Some of all the pillars of GDMT is better than all of some,” he said, crediting the phrase to a colleague. “The lowest effective dose of all 4 pillars is better than [the maximum] dose of 2 out of 4.”

In New York, Riello raised a parallel concern about administrative burden, describing specialty pharmacy as an underused partner that can absorb prior authorizations, patient assistance enrollment, and adherence outreach that otherwise fall to stretched clinic staff.

Care fragmentation was a separate concern raised by Lee Kaplan, MD, PhD, director of The Obesity and Metabolism Institute in Boston. He recalled that when he previously ran an obesity center, patients often waited 2 years to be seen, in part because of wasted effort across too many providers.

“The average patient on our waiting list had 7 complications of obesity,” he said. “They were seeing an obesity specialist, a primary care doctor, and, on average, 5 other providers. That’s 7 providers for 1 patient on average. That’s not reasonable.”

A more efficient structure, he argued, would consolidate that care under 1 or 2 providers instead of 7. “That creates an efficiency that allows us to take care of patients,” Kaplan said. “And if we take care of patients, that allows equitable access. Right now, we have the exact opposite of equitable access.”

Who Owns the Case When a Patient Sees 4 Specialists?

The New York panel’s central tension was ownership. CKM syndrome, first defined by the American Heart Association in 2023,⁵ describes the overlapping pathways linking obesity, diabetes, chronic kidney disease, and cardiovascular disease. Panelists called the framework useful but noted that nearly 90% of US adults meet criteria for at least stage I disease, making it too broad to act on without a system for triaging who needs what, and when.

Shaline D. Rao, MD, chief of the Division of Cardiology at NYU Langone Hospital–Long Island, said she has informally absorbed metabolic and weight management care for her patients with advanced heart failure because no other structure existed to catch them.

“It’s hard when you have a syndrome with so many key elements to have a key owner, and it’s too much for primary care,” she said. “It’s not so easy for any one specialist.” These patients still need nephrology, endocrinology, and cardiology input, she said, and the right model of care has not yet emerged.

Ogedegbe argued that ownership questions trace back to reimbursement: Once CMS or a payer funds a service, adoption follows. He pointed to ambulatory blood pressure monitoring, which sat largely unused in primary care for approximately 20 years until payment caught up. Panelists floated a risk-adjusted, hierarchical condition category
code tied to CKM stage as one way to align incentives with earlier intervention.

Why Disparities Persist Even Inside High-Resource Systems

Panelists in both cities connected screening and ownership gaps to equity. Beyond access to care, Ogedegbe pointed to language concordance and structural bias as separate, compounding barriers within a single health system.

“It doesn’t matter how well-educated you are. If you’re [a Black patient] in the health care system, outcomes are poorer,” he said. “We’ve seen this over and over, and it’s not about poverty or anything like that. It’s about care processes.”

Amrita Mukhopadhyay, MD, assistant professor of medicine in the Division of Cardiology at NYU Grossman School of Medicine, added that even patients who self-identify early face bottlenecks once referred, citing wait times of up to 6 months for weight-management specialists at her institution.

In Boston, Persson said her main takeaway was Kaplan’s framing of “efficiency for equitable access.” She noted that many of BMC’s underserved patients have difficulty affording co-pays for standard guideline-directed therapies, let alone out-of-pocket costs for compounded medications, and said she wants efficient processes in place to preserve access for her patients.

What Faculty Plan to Bring Back to Their Institutions

Faculty in both cities offered concrete commitments to act on over the next 6 to 18 months. In Boston, O’Brien suggested expanding pharmacists’ collaborative practice agreements to include uACR ordering. Adam Segal, MD, chair of the Division of Nephrology and Hypertension at Lahey Hospital & Medical Center, said he plans to embed clinical pharmacists more directly in his clinic. Riello said his team is building nonintrusive electronic health record prompts that surface a single missing guideline-recommended intervention at the point of care. Varsha Tanguturi, MD, medical director of CKM Compass at Mass General Brigham Population Health, said she wants to focus on moving patients across disease-specific silos over the next 6 to 12 months.

In New York, Rao said she wants to design better “landing zones of ownership” for patients who fall between specialties, leveraging electronic health record capabilities to channel them appropriately. David M. Charytan, MD, MSc, director of the Division of Nephrology at NYU Langone Health, said he plans to formalize task-shifting language in future grant submissions, and the panelists discussed piloting quality metrics to track uACR completion.

Bhatt offered a closing thought. “In the CKM space, more so than many others, it’s really important to have multidisciplinary collaboration—physicians, nurses, pharmacists, probably also involving third-party payers,” he said. “I’m just going to take back the value of making sure that as we’re trying to implement CKM strategies in our health system, we actually practice all of what we were just discussing here and not just preach it.”

References

1. Writing Committee Members; 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. Circulation. Published online June 9, 2026. doi:10.1161/CIR.0000000000001453
2. Matsushita K, Coresh J, Sang Y, et al; CKD Prognosis Consortium. Estimated glomerular filtration rate and albuminuria for prediction of cardiovascular outcomes: a collaborative meta-analysis of individual participant data. Lancet Diabetes Endocrinol. 2015;3(7):514-525. doi:10.1016/S2213-8587(15)00040-6
3. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int. 2024;105(suppl 4):S117-S314. doi:10.1016/j.kint.2023.10.018
4. Heidenreich PA, Bozkurt B, Aguilar D, et al; ACC/AHA Joint Committee Members. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022;145(18):e895-e1032. doi:10.1161/CIR.0000000000001063
5. Ndumele CE, Rangaswami J, Chow SL, et al. Cardiovascular-kidney-metabolic health: a presidential advisory from the American
   Heart Association. Circulation. 2023;148(20):1606-1635.
   doi:10.1161/CIR.0000000000001184