Simple workflow changes, such as handing a patient a urine collection cup before they leave the exam room, building automated nudges into the electronic medical record, and routing referrals through e-consults instead of new appointments, are closing cardio-kidney-metabolic (CKM) screening gaps more effectively than education campaigns alone. That was the central message from a group of cardiologists, endocrinologists, nephrologists, and pharmacists from Boston-area health systems who met for a Population Health Roundtable discussion from The American Journal of Managed Care®.
The conversation, moderated by Muthiah Vaduganathan, MD, MPH, cardiologist and clinical trialist, Brigham and Women's Hospital, brought together experts from institutions across Boston, including Mass General Brigham, Boston Medical Center (BMC), Lahey Hospital and Medical Center, the Joslin Diabetes Center, and Yale School of Medicine, to discuss how fragmented CKM care can be better coordinated across disciplines.
The event followed the release in early June of the 2026 AHA/ACC/ADA/ASN CKM guidelines, the first joint framework from the 4 leading US societies for cardiovascular, kidney, and metabolic care.1
Much of the discussion centered on urine albumin-to-creatinine ratio (uACR) testing, a biomarker that faculty said remains dramatically underused despite its value in predicting both kidney and cardiovascular outcomes.2
Closing the Screening Gap With Workflow, Not Just Awareness
The faculty pointed to specific operational fixes already improving uACR completion rates. At BMC, primary care clinics adopted a “clinic collect” model, in which medical assistants hand patients a specimen cup during rooming instead of sending them to a separate lab. This is a change that Katelyn O'Brien, PharmD, BCPS, CDCES, BC-ADM, clinical pharmacy specialist, endocrinology, Boston Medical Center, said measurably improved screening rates. Sylvia Rosas, MD, a nephrologist at the Joslin Diabetes Center, described a similar effort underway with the Beth Israel Lahey Health system to have medical assistants, rather than physicians, trigger uACR orders for patients with hypertension or type 2 diabetes.
Participants
- Muthiah Vaduganathan, MD, MPH, cardiologist and clinical trialist, Brigham and Women's Hospital (moderator)
- Jorge Plutzky, MD, director, preventive cardiology, Brigham and Women's Hospital/Mass General Brigham
- Adam Segal, MD, division chair, Lahey Hospital and Medical Center
- Emily Persson, PharmD, ambulatory clinical pharmacy specialist, cardiology, Boston Medical Center
- Varsha Tanguturi, MD, medical director, CKM Compass, Mass General Brigham Population Health
- Om Ganda, MD, MACE, senior physician and consultant, Harvard Medical School
- Lee Kaplan, MD, PhD, director, The Obesity and Metabolism Institute
- Sylvia Rosas, MD, MSCE, nephrologist, Joslin Diabetes Center
- Devin Steenkamp, MD, director of clinical diabetes, Boston Medical Center/Boston University School of Medicine
- Ralph Riello, PharmD, BCPS, clinical pharmacy specialist, cardiorenal and metabolic disorders, Yale School of Medicine
- Katelyn O'Brien, PharmD, BCPS, CDCES, BC-ADM, clinical pharmacy specialist, endocrinology, Boston Medical Center
- Sarah Finn, MD, section chief, obesity medicine, Dartmouth Health
Rosas illustrated the scale of the problem with a comparison 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%.”
Ralph Riello, PharmD, BCPS, a clinical pharmacy specialist in cardiorenal and metabolic disorders at Yale School of Medicine, described building similar nudges directly into a decision-support trial his team is running. The system identifies 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 create “heat maps” of undertreated populations, guiding where health systems should target outreach or establish community screening.
Streamlining Care Teams and Multi-Pillar Therapy
Several faculty members pointed to BMC's e-consult system as a scalable way to extend specialist input without adding appointments. The system lets 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 of several specialists 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. O'Brien said this model has expanded pharmacists' role in titrating guideline-directed therapies and managing prior authorizations, freeing physician time for diagnosis and staging.
Riello pushed back against the common practice of maximizing one drug class before adding the next. Guideline-directed medical therapy (GMT) 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.3
“Some of all pillars of GDMT [guideline-directed medical therapy] is better than all of some,” he said, referencing a phrase he credited to a colleague. “The lowest effective dose of all 4 pillars is better than the max dose of 2 out of 4 instead.”
Care fragmentation was another concern raised by Lee Kaplan, MD, PhD, director of The Obesity and Metabolism Institute. He described the burden on patients navigating multiple providers, recalling that when he ran an obesity center, patients often waited 2 years to get in and 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 would be to have only 1 or 2 providers manage all that care instead of 7 people, he added.
“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.”
What Faculty Plan to Bring Back to Their Institutions
Considering what they would act on in the next 6 to 18 months, faculty offered concrete commitments such as O’Brien’s suggestion of expanding pharmacists’ collaborative practice agreements to include uACR and improve screening.
Adam Segal, MD, division chair of nephrology at Lahey Hospital and Medical Center, said he planned to look at how his clinic was structured. “I need to utilize my clinical pharmacists more and actually maybe embed them in my clinics,” he said.
Riello said his team is building proactive, non-intrusive electronic medical record prompts that surface a single missing guideline-recommended intervention for each patient at the point of care. Others also mentioned leveraging automation in the electronic medical records to get more out of the system.
Persson said her main takeaway was Kaplan’s point about “efficiency for equitable access.” She noted that many of BMC's underserved patients struggle to afford co-pays for standard GDMTs, let alone out-of-pocket compounded medications discussed elsewhere in the conversation, and she wants to make sure there are efficient processes in place to allow for equitable access to care for her patients.
“There was a lot of discussion about crossing over silos, and a lot of the programs we have are specific to diseases,” said Varsha Tanguturi, MD, medical director of CKM Compass at Mass General Brigham Population Health. “I think one thing in the next 6 to 12 months would be making sure that we cross patients over between those [silos] or adding therapies on that could be seen as a slight expansion of the initial disease state.”
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):514-25. doi:10.1016/S2213-8587(15)00040-6
3. 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
