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

2. 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

3. 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.
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4. 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

5. 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):

6. 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

7. 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.

8. …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

9. 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

10. It’s all about perception…10

11. CKD Prevalence, Diagnosis and Annual Cost
Increased utilization
Increased hospitalization
Increased mortality
Prevalence and Medicare cost data:
United States Renal Data System 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, (9): p
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, (11): p. e
Adult Population Percentage
$3,000
$100+ billion annually
$17,000 $0
$1,700
$80,000

12. 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

13. 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

14. 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.

15. 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.