Intercepting CKD in Primary Care Elizabeth Montgomery Sr. Project Director, NKF Primary Care Initiative National Kidney Foundation July 22, 2016

How can this be? Public Health Problem Engagement Issues 22,000,000 at risk for adverse outcomes Unacceptably high rate of mortality Extraordinary utilization of health care resources Annual expenditures of a minimum of $100 billion for Medicare alone for 10% with diagnosis Patients: asymptomatic so they can’t know until a medical professional tells them. Clinicians: they have the knowledge but do not apply it in practice Insurers: It’s Medicare’s problem Federal/State/Local Government: It’s not big enough/little to do

One event has the greatest impact on improving health outcomes… Patient Clinician Diagnosis X …when a patient seeks treatment …and a clinician recognizes that the laboratory values presented represent an underlying condition that is treatable. Footer?

Diagnosis Impact of Earlier Diagnosis on Health Outcomes Symptom Onset Search for Diagnosis Initial Diagnosis& Therapy Disorder Management Impact of Earlier Diagnosis on Health Outcomes Patient Life Cycle Routine Screening: Routine BP check Lipid/cholesterol Mammogram/PAP Colonoscopy Benefits: Increased longevity Fewer complications/side effects Improved quality of life Improved productivity Reduced health-related costs Diagnosis Symptom Onset Search for Diagnosis Initial Diagnosis & Therapy Patient Life Cycle Disorder Management

Diagnosis The “typical” CKD story 85 – 90% of CKD Patients Time in primary care Disease Management On average diagnosis received 6 months before dialysis starts Hypertension Diagnosis x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x o o o o o o o o o o o o o o Missed diagnostic opportunities Age-related kidney function decline Silent progressive decline in kidney function CKD Onset Type-2 Diabetes Diagnosis Symptoms ESRD - Dialysis Average life expectancy: 5 years 85 – 90% of CKD Patients Szczech, Lynda A, et al. "Primary Care Detection of Chronic Kidney Disease in Adults with Type-2 Diabetes: The ADD-CKD Study (Awareness, Detection and Drug Therapy in Type-2 Diabetes and Chronic Kidney Disease)." PLOS One - In press (2014). Tuot, Delphine S, et al. "Chronic Kidney Disease Awareness Among Individuals with Clinical Markers of Kidney Dysfunction." Clin J Am Soc Nephrol 6 (2011): 1838-1844.

Diagnostic Delay: not exclusively a knowledge gap ≥50% <50% 0% Clinician likelihood of identifying patient with CKD (n=445 PCPs) 19 (4.3%) 217 (48.8%) 209 (47.0%) Clinician awareness: CKD screening in T2DM 100% 98.2% 97.6% Clinician awareness: <60 eGFR indicates CKD 73.7% 59.9% 57.4% >30 ACR in urine indicates CKD 57.9% 53.0% 54.5% Szczech LA, et al. PLoS One 9(11); 2014:e110535

Barriers to CKD Diagnosis CKD is a largely asymptomatic presentation. “CKD” is a relatively “new” nomenclature. Many primary care clinicians were trained before the wide availability of the NKF guidelines, they may perceive that a CKD diagnosis has little utility as there is nothing that can be done to address CKD progression. Lack of CKD diagnosis may not be understood by PCPs as a significant contributor to adverse events or a patient safety concern. The absence of ongoing, timely feedback regarding the accuracy of CKD diagnosis may contribute to clinician overconfidence in CKD diagnosis. Primary care clinicians (PCP) are trained (and compensated) to treat acute illness – there are challenges to implementing a chronic disease care model in primary care.

…a major public health initiative leveraging demonstrated best practices in large scale change in health care. Consumers/ Patients Patient Journey Research Laboratory Interventions Improve engagement channels Tools to improve communication Medical Societies/ Healthcare Providers Laboratory Profiling New approaches to CME Quality Improvement & Maintenance of Certification CME Research New tools Process changes (CPT Codes) IMPROVED AWARENESS Patient Clinician Diagnosis Insurers (Payers and Malpractice) Performance Measures Pay for performance Population Health Interventions Disease Management/ Wellness Programs X Academia Med School Training Residency curriculum Research System Hospitals & Health Networks Improved communication Quality Improvement activities Developing performance measures Process changes (CPT codes) Government Pay for Performance Performance measures Research Population Health Interventions Industry (Laboratory, Diagnostic, & EMR) Medical Home Laboratory Innovations Novel approaches to testing

Population Health Model for CKD: Establish preservation and protection of kidney health as a public health priority. Ensure that assessment of kidney function is routine standard of care for at-risk populations in primary care. Provide training and materials so that clinicians routinely engage their patients in conversations about the importance of kidney health and actively support patient alignment with behaviors that will protect it. Provide people living with CKD the tools, information and resources necessary to make informed choices to protect their kidney health

It’s all about perception… 10

CKD Prevalence, Diagnosis and Annual Cost Increased utilization Increased hospitalization Increased mortality Prevalence and Medicare cost data: United States Renal Data System. 2015 USRDS annual data report: Epidemiology of Kidney Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2015. Cost per stage attributable to CKD: Honeycutt, A.A., et al., Medical costs of CKD in the Medicare population. Journal of the American Society of Nephrology : JASN, 2013. 24(9): p. 1478-83. CKD Diagnosis: Szczech, L.A., et al., Primary care detection of chronic kidney disease in adults with type-2 diabetes: the ADD-CKD Study (awareness, detection and drug therapy in type 2 diabetes and chronic kidney disease). PloS one, 2014. 9(11): p. e110535.   Adult Population Percentage $3,000 $100+ billion annually $17,000 $0 $1,700 $80,000

Kidney Disease Data Mining Most people won’t solve a problem that they cannot see Case Study: Payer Group Over 3 million lives covered Before intervention: ~ 17,000 people with diagnosed CKD in database After intervention: 155,430 people with probable undiagnosed CKD identified Kidney Disease Data Mining Illuminating the problem to engage and improve Case Study: Primary Care Network Almost 140,000 lives covered After intervention: 12,000 with probable undiagnosed CKD identified Case Study: Large Integrated Health Network Almost 500,000 lives covered 80% of patients with Stage 5 CKD not referred for nephrology 65% of patients with Stage 4 CKD not referred to nephrology 50% of patients with eGFR<60 on recommended medications

Leadership summit to develop CKDinsight Leadership summit to develop CKD Roadmap for change Participants CMS HHS IBM Advocate Health OhioHealth Humana Dialysis Clinic, Inc. Walgreens AAFP, AANP Quest Laboratories Anthem HCSC And others…. Dr. Regina Benjamin 18th US Surgeon General

Insight Integrate Inform Program Components 2016 A leadership summit to clearly identify obstacles, define strategies to overcome them and build collaboration and momentum. Integrate Leveraging data mining and facilitated practice transformation to identify and manage CKD. Inform Innovative educational strategies for health professionals and people living with CKD.

Thank you! Our Mission Our Vision The National Kidney Foundation, a major voluntary nonprofit health organization, is dedicated to preventing kidney and urinary tract diseases, improving the health and well-being of individuals and families affected by kidney disease and increasing the availability of all organs for transplantation. Our Vision To enhance the lives of everyone with, at risk of or affected by kidney disease. Key Fact The National Kidney Foundation is the leading organization in the U.S. dedicated to the awareness, prevention and treatment of kidney disease for hundreds of thousands of healthcare professionals, millions of patients and their families, and tens of millions of Americans at risk.