1. CKD Primary Care Initiative Medical Advisory Board Webinar January 29, 2015 2:00 pm Eastern

2. Status of Survey Monkey Data Primary Care Initiative: Big Hairy Audacious Goal Framing CKD as a Patient Safety Issue Agenda: CKD Primary Care Initiative Transforming care. Saving lives.

3. ■ Survey Monkey data captured January 2015 illustrates: ■ Many laboratories reporting eGFR <60 ■ Suggests that few clinical laboratories provide CKD decision support ■ Opportunity exists for NKF to address these issues in laboratory engagement campaign. Thank you for your input 3 CKD Primary Care Initiative Transforming care. Saving lives.

4. 20% of the CKD Population by 2020 Increase diagnosis to Primary Care Initiative activities will facilitate diagnosis of 2 million people living with CKD by 2020. 4 Big Hairy Audacious Goal

5. 20% of the CKD Population by 2020 Increase diagnosis to What strategies can be used to measure this? 5 Big Hairy Audacious Goal

6. XX% of primary care clinicians could articulate CKD diagnostic criteria yet only XX% of people with CKD were diagnosed. XX% of people with impaired kidney function had eGFR data in record yet only XX% of people with CKD were diagnosed. ADD-CKD Study: 6 CKD Primary Care Initiative Transforming care. Saving lives. Reframing CKD

7. Over half of primary care clinicians recognize CKD diagnostic criteria yet only 12.1% of people with CKD were diagnosed. 84.8% of individuals with type-2 diabetes had eGFR data in the past 15 months yet only 12.1% of people with CKD were diagnosed. ADD-CKD Study: Szczech LA, et al. PLoS One 9(11); 2014:e110535 CKD Primary Care Initiative Transforming care. Saving lives.

8. Primary Care Initiative Messaging: Must illuminate different interpretations of the relevance of CKD not challenge the accuracy of existing mental models. 8

9. The perennial question associated with CKD diagnosis is: Will making a CKD diagnosis make a difference to outcomes… ?

10. Improved Diagnosis… Studies demonstrate that clinician behavior changes when CKD diagnosis improves: 10 CKD Primary Care Initiative Transforming care. Saving lives. -significant improvements realized in -Increased urinary albumin testing -Increased appropriate use of ACEi or ARB -Avoidance of NSAIDs prescribing among patients with low eGFR -Appropriate nephrology consultation

11. 1. Wei, L., MacDonald, T. M., Jennings, C., Sheng, X., Flynn, R. W., & Murphy, M. J. (2013). Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug prescribing and increased renal function. Kidney In, 84(1), 174-8 2. Chan, M. R., Dall, A. T., Fletcher, K. E., Lu, N., & Trivedi, H. (2007). Outcomes in patients with chronic kidney disease referred late to nephrologists: a meta-analysis. Am J Med, 120(12), 1063-1070. NSAID prescribing decreased after the implementation of eGFR reporting, and there were significant improvements in estimated renal function in patients who stopped taking NSAIDs. Hence, eGFR reporting may result in safer prescribing. 1 There was significantly increased overall mortality in the late referral group as compared with the early referral group (relative risk 1.99; 95% confidence interval [CI], 1.66 to 2.39, P <.0001). The duration of hospital stay, at the time of initiation of renal replacement therapy, was greater in the late referred group by an average of 12 days. 2 Improved Diagnosis Improves Outcomes 11 What other specific examples should we highlight?

12. Primum non nocere Improved diagnosis creates opportunity for strategic preservation of kidney function Fink, Jeffrey C. et al. “Chronic Kidney Disease as an Under-Recognized Threat to Patient Safety.” American journal of kidney diseases : the official journal of the National Kidney Foundation 53.4 (2009): 681–688. PMC. Web. 27 Jan. 2015. 12

13. Acute Kidney Injury An Acute Kidney Injury (AKI) event has been identified as a precipitating cause in 10-20% of ESRD cases. US $ 3 – 6 billion annually associated with AKI-related End-State related costs alone Lee, P., Johansen, K., & Hsu, C.-y. (2011). End-stage renal disease preceded by rapid declines in kidney function: a case series. BMC Nephrol, 12(5) 13

14. Almost half of AKI-related emergency room admissions with poor treatment outcomes received a new diagnosis of CKD on admission. 1 ://www.ncepod.org.uk/2009report1/Downloads/AKI _report.pdf ://www.ncepod.org.uk/2009report1/Downloads/AKI _report.pdf Hospital-acquired AKI represents 5% of annual hospital admissions resulting in US $10 billion in health care expenditures. 2 AKI occurred in over 1 of 5 hospitalizations and was associated with a more than fourfold increased likelihood of death. 3 Acute Kidney Injury 1. National Confidential Enquiry into Patient Outcome and Death. (2009). National Confidential Enquiry into Patient Outcome and Death. Retrieved January 2015, from Adding Insult to Injury: A review of the care of patients of died in a hospital with a primary diagnosis of acute kidney injury 2. Chertow, G. M., Burdick, E., Honour, M., Bonventre, J., & Bates, D. W. (2005). Acute kidney injury, mortality, length of stay, and costs in hospitalized patients. J Am Soc Nephrol, 16, 3365-3370. 3. Muntner P, Chertow GM, Warnock DG. Acute Kidney Injury and Mortality in Hospitalized Patients. American Journal of Nephrology2012;35(4):349-355. 14

15. Improved Diagnosis Improves Medication Management 26% of CKD patients were prescribed potentially harmful drugs in last 12 months in primary care practices. 1 Failure to adjust medication doses to the current level of kidney function may occur is as many as half of hospitalized patients. Impaired kidney function and medication errors may contribute to 10% of hospital admissions annually, much of which may be preventable. 2 1. Allen AS, Forman JP, Orav EJ, Bates DW, Denker BM, Sequist TD. Primary Care Management of Chronic Kidney Disease. Journal of General Internal Medicine 2011;26(4):386-392. 2. Leendertse, A. J., van Dijk, E. A., De Smet, P. A., Egberts, T. C., & van den Bernt, P. M. (2012). Contribution of renal impairment to potentially preventable medication-related hospital admissions. Ann Pharmacother, 46, 625-633 15 Your thoughts or comments?

16. “Paid more attention to my labs because my doctor should have told me years sooner that I had kidney disease. I would have stopped taking any NSAID'S years sooner and monitored my diet more seriously.” NKF FACEBOOK Post: If I was told I had kidney disease before my kidneys failed I would have _______ 16 Improved Diagnosis Improves Patient Engagement CKD Primary Care Initiative Transforming care. Saving lives.

17. The National Kidney Foundation is the most EFFECTIVE + LONGSTANDING organization fighting kidney disease through awareness, prevention, and treament. Acute hospital days: by year (source: Ministry of Health, BC Medical Services Plan). Levin A et al. Nephrol. Dial. Transplant. 2009;ndt.gfp180 17 Improved Diagnosis Is Population Health

18. “Our goal is to have 85% of all Medicare fee-for-service payments tied to quality or value by 2016, and 90% by 2018. Perhaps even more important, our target is to have 30% of Medicare payments tied to quality or value through alternative payment models by the end of 2016, and 50% of payments by the end of 2018.” “Improving the way care is delivered is central to our reform efforts. We have put in place policies to encourage greater integration within practice sites, greater coordination among providers, and greater attention to population health.” Published January 26, 2015 On NEJM.org 18

19. Patient safety is population health… X X X X X X X X X X X X X X X CMMI Transforming Clinical Practice Phase 2 Milestones Practice starts to capture and analyze population, disease specific and relevant quality measures for utilization, billing data and tests to drive clinical practice improvement and resulting in reducing unnecessary tests and hospitalizations. The practice provides care management to at least 50% of highest risk patients (those that are clinically unstable). The practice implements at least three specific care management strategies for patients in higher risk cohorts. Practice will incorporate regular improvement methodology to execute change ideas in a rapid cycle. Clinically Unstable Highest Risk Highest Cost Diabetes CKD Hypertension

20. Patient Safety To Err is Human grossly underestimated the rate of serious harm incurred in US health care settings. Estimated that over 400,000 inpatient deaths associated with preventable deaths annually. 4 – 8 million people experience preventable adverse events in US hospitals annually James, JT – 2013 – J Pat Safety 9(3):122-128 “If the hospital data are correct, and if all other areas of health care contribute to even half as many deaths, then preventable adverse events in health care has eclipsed heart disease as the leading cause of death in the United States.” Card, AJ – J Health Care Risk Management 34(1) 2014 CKD Primary Care Initiative Transforming care. Saving lives.

21. Primary Care Initiative Messaging: Must illuminate different interpretations of the relevance of CKD not challenge the accuracy of existing mental models. 21 Your thoughts or comments?

22. Upcoming events 22 CKD Primary Care Initiative Transforming practice. Saving lives. Medical Advisory Board Meeting at NKF Spring Clinical Meeting: Saturday, March 28, 2015, 3:00 pm Scheduled Webinars: April 23, 2015, 2:00 pm Eastern: What ADD-CKD Means to the PCI Education Strategy July 14, 2015, 2:00 pm Eastern: Factors Contributing to CKD Diagnostic Delays

23. THANK YOU Elizabeth Montgomery Elizabeth.Montgomery@kidney.org 212.889.2210 x 196