Intercepting CKD in Primary Care Presented by Elizabeth Montgomery National Kidney Foundation April 20, 2015

1984 2014 Breast Cancer Not openly discussed or commented on. A diagnosis that inferred little to be done and very little hope. Low primary care awareness, knowledge or engagement Breast Cancer Culture Change Widely regarded as a public health threat. Widely recognized for its impact on mortality and health care costs. Included in routine preventative screening in primary care. Diagnostic delays are not tolerated by the public or the system. Twenty-five years ago, when …, you heard very little about breast cancer. Most people couldn’t describe the value of a mammogram. Many primary care doctors could not articulate the various strategies to prevent breast cancer or to treat it. But a culture change occurred, primary care clinicians moved from reacting to late stage, progressed disease into prevention and early treatment. Because of this shift, today breast cancer claims fewer lives each year than kidney disease does. That culture change occurred because of group of committed people made the decision to find solutions. 2014

10% Percentage of people with CKD that today know that they have CKD. The majority have advanced CKD, are on dialysis or awaiting transplant. 90% Who cannot know they have CKD until a medical professional tells them. Are unaware that advancing CKD places them at significantly greater risk for heart attack, stroke or death. Have no opportunity to be proactive, make informed choices or protect their kidney health. At any given moment, only 10% of people with CKD know that their kidney function is impaired. That’s 1 out of 10 people with CKD know that they have CKD. Unfortunately, those that are aware of their CKD are generally people whose kidneys are failing or have already failed, primarily dialysis patients or people preparing for transplant. 9 out of 10 people with CKD don’t know they have CKD. They have absolutely no idea that they face a 30 times greater risk of heart attack, stroke or premature death. Because CKD has no easily recognizable symptoms early in its progression, they are completely unaware that their kidneys are slowly and silently failing them. They cannot know that their lives are seriously at risk until a medical professional tells them. A staggering 20 million people are living with countdown clocks ticking away in their lives, completely unaware of how abruptly, dramatically and irreversibly their lives will change. These individuals have no power to choose; they have no opportunity to be proactive; they have no chance to protect their health. Sadly, in this moment, today, the majority of people living with CKD cannot count on the healthcare system to help protect them. 3

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% Because of local support in communities like yours, the NKF recently sponsored a large study to determine what percentage of CKD patients are accurately diagnosed by their primary care doctor. It was astounding to confirm that the majority of people with CKD were not accurately diagnosed. More astounding was the fact that many people who were newly diagnosed as part of the NKF study had laboratory findings in their medical record indicating that their kidneys were impaired. There was vital information in the medical record that their primary care doctor did not either recognize or respond to. The data was there – but no diagnosis was rendered. This same study showed that the majority of physicians that did not accurately diagnose patients with CKD were indeed capable of describing the markers for CKD. To be clear: the doctors who did not diagnose chronic kidney disease in their patients were capable of clearly articulating how and when to diagnosis Chronic Kidney Disease. This is a little mind-boggling isn’t it? ***** Szczech LA, et al. PLoS One 9(11); 2014:e110535

Improve Quality of Care Improve Patient Engagement OBJECTIVES Improve Diagnosis Improve Quality of Care Improve Patient Engagement You might ask how this can be. Many factors contribute to this situation: How doctors are trained may orient them to recognizing CKD only when the symptoms appear. How physicians are compensated encourages them to treat what is in front of them instead of supporting prevention. Many doctors were trained well before the availability of the KDOQI guidelines and may still consider that CKD cannot be slowed down or stopped. These may be considered significant issues but these are very similar to the challenges associated with breast cancer 25 years ago. The perception was that there was very little hope and very little to be done. People became inspired to fight breast cancer and that perception changed. *** It is the mission of the NKF CKD Primary Care Initiative to address the misperceptions about CKD. We will transform CKD care from a reactive, symptom-driven response into a proactive model of early recognition & prevention. There are proactive steps that can be taken by CKD patients and the health professionals who care for them that will protect and preserve kidney function. Accurate and timely diagnosis is vital. Accurate and timely diagnosis allows primary care doctors to utilize methods proven to stop CKD progression in its earliest stages. Accurate and timely diagnosis leads to protection of kidney health and will save tens of billions of dollars annually in health care utilization for private insurers and lost productivity for most employers. Most importantly, accurate and timely diagnosis will give CKD patients a voice in determining their own future.

Double the number of people with CKD that know that they have CKD by 2020. Two simple, widely available laboratory tests diagnose CKD. As primary care doctors are play a crucial role in preserving kidney health and are the best defense against CKD progression, it is our goal to establish kidney function assessment as routine practice in primary care. Through innovation and strategic partnerships we will develop avenues to reach large numbers of undiagnosed CKD patients and the doctors who care for them to improve the timeliness of accurate CKD diagnosis. To facilitate this change, we are working with prominent medical societies and associations to offer new approaches to CKD recognition and patient care. We are expanding our consortium of diverse stakeholders to extend our reach, raise our voice and further our message. *** We are committed to preserving the future of the 20 million people whose CKD countdown clocks are still ticking. We intend to double the number of people who have an accurate diagnosis of CKD by the year 2020. This may seem like a bold goal, but we have a clear path for achieving it. ****

Create a culture in primary care where: VISION: Create a culture in primary care where: preservation and protection of kidney health is a public health priority. testing and diagnosis of CKD is routine standard of care for at-risk populations. clinicians routinely engage their patients in conversations about the importance of kidney health and actively support patient alignment with behaviors that will protect it. Double the number of people with CKD that know they have CKD by 2020. Twenty-five years ago the world perceived breast cancer very differently – there was little to be done and very little hope. We live in a different world today because we as a society made the choice to drive a culture change that incorporated many different strategies to change the thinking of the American public, the professionals who cared for them and the health care system that supported them. Today, we as a society will not tolerate delays in the diagnosis of cancer, I would like to suggest that we should not accept delays in the diagnosis of kidney disease. The NKF Primary Care Initiative will transform CKD care into an active posture of prevention, early detection and aggressive management. By 2020, we will double the number of people with CKD that know they have CKD and we will empower them with the information and resources they need to make choices to protect their kidney health. We can achieve all this… With your help…

…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 CKDintercept is a major public health initiative with programming being developed for engagement and collaboration with every stakeholder group associated with primary care. These individual programs will unfold over time – along a timeline developed to ensure that we create the greatest possibility for success in the shortest amount of time. System Hospitals & Health Networks Improved communication Quality Improvement activities Developing performance measures Process changes (CPT codes) Industry (Laboratory, Diagnostic, & EMR) Medical Home Laboratory Innovations Novel approaches to testing Government Pay for Performance Performance measures Research Population Health Interventions

Early Detection and Prevention A Primary Care Initiative PCP-in-a-Box is now… CKDinform is the first program under the CKDintercept umbrella to be unveiled. CKDinform is targeted to those clinicians who are aware that opportunities to improve CKD diagnosis and management exist in their practices. Early Detection and Prevention

Clinicians with known/perceived gaps Limited Application Of CKD Aware of Practice Gaps “Conscientious Clinicians” CKDinform Audience Clinicians with known/perceived gaps Limited Application Of CKD Guidelines Demonstrated Application of CKD Guidelines Lack the calibration between knowing and doing to recognize need for improvement CKDinform is designed to help those clinicians already looking to improve their CKD care practices. These are clinicians who are simply committed to personal improvement – or those who may have become aware of opportunities for improvement through some adverse event involving a patient. These are clinicians who are interested in aligning CKD care in their practice with established CKD guidelines – KDOQI. This education experience provides practical suggestions for CKD practice transformation as well as CKD assessment and management tools that may be easily integrated into the practice work flow. Future CKDintercept programs – such as CKD Practice Transformation programming – will build on the CKDinform platform to include innovative strategies to address those clinicians in the lower two quadrants of the grid – those that are unaware that they are not appropriately diagnosing CKD and/or unaware that they are not delivering guideline concordant care. The activities to be unveiled later this year will help clinicians recognize gaps in CKD care within their practices and utilize demonstrated strategies to develop a culture of kidney protective care. Innovative Strategies are necessary Clinician Unaware of Practice Gaps

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