A Perspective on CKD Management Mony Fraer May 2014

Topics 1. CKD - Model of a Chronic Disease 2. Chronic disease burdens 3. Multidisciplinary Care 4. Patient engagement 5. The UK model

> 13 % adults with CKD > 15 million with stage 3 CKD Prevalence of CKD: 5% /year growth patients are complex and at high-medical risk (risk of reduced all-cause mortality, CVD, infection, AKI) risk of death from CVD > progression to ESRD CV risk reduction - management of CKD/slowing progression CKD - Model of a Chronic Disease

Financial Burdens ad Barriers before starting dialysis, majority of costs are from hospitalizations (6 mo. before initiation of dialysis) month of initiation of dialysis: $25,000 - $35,000. annual cost: CKD ($28,000 - $65,000 ) and ESRD ($85,000 ) annual cost: $5,000 for CHF and $10,000 for DM Government/payers are demanding value ( = quality/cost) reimbursement models that do not align incentives for all involved

The Problem Management of advanced CKD is suboptimal (irrespective of whether patients are treated by nephrologists or non- nephrologists)

Causes late diagnosis of CKD lack of awareness - magnitude and significance of CKD fragmentation of care with (multiple caregivers in myriad settings) late referral to nephrology insufficient use of therapies to slow CKD progression insufficient treatment of complications/comorbidities abrupt transition to renal replacement therapy

Causes solitary physician visits - not an appropriate care model CKD disparities (racial, ethnic, socio-economic) ESRD patients fragmented care lack of attention to comorbid conditions failure to provide preventative services

Aims 1. Early identification of CKD and its complications 2. Delay/prevent progression of CKD and need for RRT: 3. Management of the comorbid conditions 4. Smoothing the transition to ESRD and RRT 5. Attention to avoidable hospitalizations

Nephrologists > 2000 CKD patients/nephrologist usually nonprogressive disease and not necessarily requiring specialized care no formal involvement of the PCP beyond the traditional communication of a clinic note

Primary Care Physicians limited time to deliver appropriate/recommended chronic disease mgmt. (CDM) in addition to diagnosing new problems and providing preventive care large number of MD’s - not aware of KDOQI guidelines overlap between DM, CVD and CKD, it is possible that physicians prioritize treatment for DM and CVD (link between these and CKD)

Patients as Self-managers Complex treatment regimens Monitor their conditions Make lifestyle changes Make decisions about when to seek professional care and when they can handle a problem on their own High level of knowledge, skill, and confidence

Education Patient awareness, education, empowerment in decision making and repeated interactions with the care team dietary counseling medication management ongoing education about RRT/conservative care about the condition other behaviors National Kidney Foundation tools:

Patient Engagement Assessing depression Patient activation measures (patient knowledge, skill, and confidence for self-management) Medication adherence Self-efficacy Disease knowledge

Questions to Answer 1. How to leverage the expertise of nephrologists 2. At which stage of CKD should patients be referred to a nephrologist 3. What is the level of expertise that can be expected of PCP’s in the mgmt. of CKD 4. Best way to involve allied health professionals in multidisciplinary CKD care 5. Is there a point, before ESRD, at which the nephrologist should assume primary care of a patient with CKD

Multidisciplinary Care Elements of a CKD model of care: Early identification of patients Longitudinal protocolized follow-up (as opposed to episodic care) Interventions to delay progression Timely preparation for RRT/or planning for conservative care

The Team Nurses PCP’s Nephrologists Dietitians Cardiologists, endocrinologists, vascular surgeons, transplant physicians Other: physiotherapists, social workers, and psychologists

Implementation of Care Models data management tools education programs (for team members) communication tools formalized protocols guideline-driven approach restructuring of practices to multidisciplinary teams computerized decision-making support

Pharmacists

Navigator/Case manager changes in patient status - appropriate team members are involved at the appropriate time for specific patients. help the patient and their family understand where they are in the spectrum of disease

More Prominent Involvement of PCP’s - stable kidney function/slowly progressive -issues of reversibility have been addressed -measures implemented to slow progression -comorbidities and CV risk factors have been addressed -had dietary counseling

More Prominent Involvement of PCP’s -have made modality decisions and have a plan for the start of RRT -on all appropriate medications -reasonable achievement of target BP -stabilization of laboratory parameters associated with CKD The ability of the PCP to liaise with the MDC team must be effortless

Results integrated care (comprehensive, team-based, MDC for CKD and comorbidities) vs. usual care (PCP management using outside nephrology consultation) : - slower decline in GFR over time - lower percentage of patients initiating dialysis

Through the Looking Glass: A New Perspective on Population Management

The UK Model Closed managed care system funded by the government and paid for by general taxation Among the lowest health care spenders of OECD All practices are fully computerized and >97% receive lab results electronically (will detect CKD at the primary care level)

The UK Model Strategic planning for kidney services (public health problem)- primary care priority - guidelines selecting patients for referral to specialized care -quality outcomes framework system rewards physicians for tracking specific evidence-based indicators in CKD -specialized multidisciplinary clinics

The UK Model In the first 2 y > 40% of the expected CKD 3 to 5 population registered in primary care

Can we do it? Assessing depression, patient knowledge, skill, and confidence for self-management, medication adherence Referral charts (decision making trees) for primary care Multidisciplinary clinics Incentives (insurers, employers) UK type level of integration and decision making