Download Elizabeth Montgomery - Florida Renal Administrators Association

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
• Patients: asymptomatic so they can’t
know until a medical professional tells
them.
• 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
• 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…
Diagnosis
Patient
…when a patient seeks treatment
Footer?
X
Clinician
…and a clinician recognizes that
the laboratory values presented
represent an underlying condition
that is treatable.
Impact of Earlier Diagnosis
on Health Outcomes
Patient Life Cycle
Symptom Onset
Routine Screening:
Routine BP check
Lipid/cholesterol
Mammogram/PAP
Colonoscopy
Search for Diagnosis
Initial Diagnosis&
Therapy
Diagnosis
Disorder Management
Benefits:
Increased longevity
Fewer complications/side effects
Improved quality of life
Improved productivity
Reduced health-related costs
Patient Life Cycle
Symptom Onset
Search for
Diagnosis
Initial Diagnosis &
Therapy
Disorder Management
4
The “typical” CKD story
Diagnosis
Time in primary care
Age-related kidney
function
decline
Disease Management
On average diagnosis
received 6 months before
dialysis starts
Missed diagnostic opportunities
Hypertension
Diagnosis
o o o o
o
o
o
o
o
o o
o
o
o
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 xx
Silent progressive decline in kidney function
Type-2
Diabetes
Diagnosis
Symptoms
CKD Onset
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): 18381844.
Diagnostic Delay: not exclusively a knowledge gap
Clinician likelihood
of identifying
patient with CKD
(n=445 PCPs)
Clinician awareness:
CKD screening in
T2DM
Clinician awareness:
<60 eGFR indicates
CKD
Clinician awareness:
>30 ACR in urine
indicates CKD
≥50%
<50%
0%
19 (4.3%)
217 (48.8%)
209 (47.0%)
100%
98.2%
97.6%
73.7%
59.9%
57.4%
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.
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Patient Journey
Research
Laboratory Interventions
Improve engagement channels
Tools to improve communication
IMPROVED
AWARENESS
Consumers/
Patients
•
Performance
Measures
Pay for performance
Population Health
Interventions
Disease Management/
Wellness Programs
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Diagnosis
X
Patient
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Medical Societies/
Healthcare
Providers
Laboratory Profiling
New approaches to CME
Quality Improvement &
Maintenance of Certification
CME
Research
New tools
Process changes (CPT Codes)
Clinician
•
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System
Insurers
Med School Training
Residency
curriculum
Research
Academia
(Payers and
Malpractice)
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Medical Home
Laboratory Innovations
Novel approaches to
testing
•
Industry
(Laboratory, Diagnostic,
& EMR)
Government
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Pay for Performance
Performance measures
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Hospitals &
Health
Networks
Research
Population Health Interventions
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Improved communication
Quality Improvement
activities
Developing performance
measures
Process changes (CPT codes)
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
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Increased utilization
Increased hospitalization
Increased mortality
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.
6
Prevalence
CKD Diagnosis
5
Adult Population Percentage
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.
4
3
2
$3,000
1
$100+ billion annually
$17,000
$0
$1,700
$80,000
0
Stage 1
Stage 2
Stage 3
Stage 4
Stage 5
Most people won’t
solve a problem that
they cannot see
Kidney Disease Data Mining
Illuminating the problem to engage
and improve
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
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
CKDinsight
Leadership summit to develop
CKD Roadmap for change
•
Dr. Regina Benjamin
18th US Surgeon General
Participants
– CMS
– HHS
– IBM
– Advocate Health
– OhioHealth
– Humana
– Dialysis Clinic, Inc.
– Walgreens
– AAFP, AANP
– Quest Laboratories
– Anthem
– HCSC
– And others….
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Program Components 2016
Insight
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
The National Kidney Foundation, a major voluntary nonprofit health organization, is
dedicated to preventing kidney and urinary tract diseases, improving the health and wellbeing 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.