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Identifying & Managing Chronic Kidney Disease - Part 1: Understanding CKD and Who is At Risk

Understanding Chronic Kidney Disease in the US

According to the National Institute of Health, chronic kidney disease (CKD) is common in adults in the US, with more than 37 million American adults living with the disease1. In advanced stages, CKD can lead to end-stage renal disease (ESRD), resulting in associated healthcare costs of over $49 billion per year. A natural area for cost and outcome improvement is for providers to identify patients in the mid to late stages of chronic kidney disease to intervene with preventive care management to better manage their condition and help avoid disease progression3. However, CKD can be difficult to diagnose, with many patients not presenting symptoms until the disease has progressed to later stages. It is crucial to identify patients at elevated risk of chronic kidney disease early as this population is often living with other associated chronic diseases such as diabetes, hypertension, COPD, or heart failure, and may also include factors such as obesity, age, or tobacco use4.

The kidneys are responsible for removing waste products and extra water from our bodies, making red blood cells, and even assisting in regulating blood pressure. Damage to the kidneys can cause waste to build in the body and as the kidneys struggle to function, there is an increased risk for other health problems like heart failure and hypertension to occur. This could also lead to an eventual end stage in which a person requires dialysis to clean their blood. In most cases, CKD is a slow progression (sometimes with few warning signs at all). By managing other comorbidities, remaining active, eating well, taking prescribed medications, and making other important lifestyle changes, CKD progression can be slowed, providing patients time to understand how to manage the disease and make better choices for their overall health3.

Chronic Kidney Disease & Value-Based Care Programs

With an increasing emphasis on value-based care, effective care management offers a number of ways for healthcare systems to improve the health outcomes of patients with CKD and/or other comorbidities. It can be challenging to effectively measure the impact of value-based programs on patients living with CKD or ESRD and past programs have seen mixed results in improving quality and reducing costs2. However, targeting CKD patients or patients with other chronic diseases can open opportunities to slow disease progression and positively impact the health and lives of these populations3. Healthcare organizations can focus on specific areas of improvement, such as population/risk identification, quality measurement reporting, or active care coordination and management efforts. Utilizing Azara Healthcare’s ecosystem of value-based care solutions, such as Azara DRVS and Azara Care Connect, can help drive quality improvement and lead to targeted, efficient care for those in greatest need.

With an increasing emphasis on value-based care, effective care management offers a number of ways for healthcare systems to improve the health outcomes of patients with CKD and/or other comorbidities.

In the US, value-based care programs are evolving, with models focused on preventive care and improving patient health outcomes. The Kidney Care Choices (KCC) Model is a Centers for Medicare & Medicaid (CMS) program that provides financial incentives for organizations to manage the care of patients with late-stage CKD to help delay the onset of dialysis and incentivize kidney transplantation6. KCC aims to reduce the number of persons developing kidney failure through initiatives to offer “higher quality kidney care.” This CMS model targets CKD patients in stages 4 or 5 who “experience fragmented care and high-cost treatments that do little to slow disease progression.” Outlining ways to identify this population by casting a wide net (targeting chronic disease patients without kidney profile lab results) is important as most living with CKD “receive limited to no education about their disease and treatment options”6. Although KCC focuses on Nephrologist practices, the need to coordinate and manage the care of this population is an opportunity across many spectrums of healthcare. Along with reducing the number of patients developing complete kidney failure, KCC strives to educate the population to help them become more actively engaged in the management of their health.

KCC focuses on three areas. First is the Patient Activation Measure, or PAM, a survey that determines how activated a patient is regarding their care. Depression Remission is the second, providing patients with PHQ-2 and PHQ-9 screenings. Finally, Optimal Starts in ESRD. An optimal start has been shown to improve CKD patients' outcomes, focusing on education surrounding access placement, modality choice, and preemptive kidney transplants8. Efforts in these areas can be completed with care coordination and care management. By building out a care plan with the patient’s health in mind, care management efforts can focus on medication adherence to ensure the patient is on an ACEi/ARB Therapy or an SGLT2 Inhibitor—both medications are shown to slow the progression of kidney disease4. Educational materials can also be supplied to CKD patients in areas such as dialysis, transplants, and lifestyle changes like nutrition and exercise.

CKD Risk Assessment

The National Kidney Foundation (NKF) has been a valuable resource for kidney care patients and all those affected by the disease. One tool used to classify patients with CKD is NKF’s CKD Risk Assessment Tool, shown below:

CKD Heat Map

The sooner a person receives the necessary test results, the sooner treatment and management of the disease can occur. This tool provides a breakdown of prognosis based on an individual's glomerular filtration rate (GFR) and albuminuria ranges [5]. Using the above risk assessment can be a great first step to help improve the identification of those with CKD from stages 1 to 5. However, this tool is only useful when healthcare organizations can access a patient’s lab results.

By better understanding CKD and other comorbidities that lead to kidney damage, healthcare organizations can focus on identifying this high-risk population. The two most at-risk are diabetic and hypertensive patientsalmost 1 in 3 patients living with diabetes also has a CKD diagnosis, while 1 in 5 diagnosed with high blood pressure also live with CKD. Knowing these two risk factors provides an opportunity to identify patients who need a kidney profile to assess the status of their kidney health.

Almost 1 in 3 patients living with diabetes also has a CKD diagnosis, while 1 in 5 diagnosed with high blood pressure also live with CKD.

In Part 2 of this series, I will highlight ways to service those at higher risk of CKD using Azara solutions to identify and manage the increasingly growing population of patients without kidney profiles and/or other chronic conditions.

> Read Part 2 Now