By Judie Bizzozero
Chronic kidney disease (CKD) is a growing health problem reaching epidemic levels in the United States, and a multidisciplinary, coordinated care approach is required to improve patient outcomes and constrain escalating healthcare costs associated with the disease.
More than 25 million Americans suffer from CKD, and that patient population will continue to rise as the rates of obesity, diabetes and hypertension increase. Affected patients also are at increased risk for cardiovascular disease and congestive heart failure and ultimately will progress to end-stage renal disease (ESRD) that will require life-long dialysis or kidney transplantation.
The Integrated Care Management Paradigm
Integrated care, coordinated care and accountable care are the latest terms that weave in and out of discussions focusing on renal disease management concepts and evidence-based, guideline-driven care concepts.
The concepts of appropriate co-management of patients with renal disease is a very timely topic in the CKD world because the continuum of care recognizes there is a clear point in which the primary care physician (PCP) needs the assistance of the nephrologist and there are comorbid conditions that require continued treatment as renal disease progresses, said Franklin W. Maddux, MD, FACP, senior vice president and chief medical information officer at Fresenius Medical Care North America.
There are substantial opportunities in renal disease to coordinate care from the very early at-risk patient to the CKD population that is heavily comprised of patients with underlying diabetes, hypertension, cardiovascular disease and other genetic and familial type kidney diseases.
“The CKD population is quite large, and an enormous public health burden because it represents as many as 26 million people in the population,” he said. “If you begin to funnel down and winnow out those patients that progress with advancing renal insufficiency, where the function of those kidneys is not fully effective, you recognize that most of those original at-risk and early-stage patients are being seen by family practitioners, general internists and other primary care healthcare providers.”
Allen R. Nissenson, MD, FACP, chief medical officer at DaVita, believes one of the biggest overall problems for both CKD and ESRD patients is the fragmentation of care delivery that leads suboptimal clinical outcomes and high costs and creates a high burden of disease on patients and the healthcare system.
He said clinical outcomes will improve and the overall cost of care will be kept in check if a policy is in place that provides well-organized, proactive approaches to keeping patients healthy and out of the hospitals. Because CKD patients have multiple comorbid conditions they see many different doctors or healthcare providers in many different settings, which can lead to multiple adverse consequences such as conflicting medications and redundant testing.
“The communication among the various moving parts is very poor, which leads to at a minimum inefficient care delivery and an inconvenience for the patient,” he said. “Ultimately, it can lead to poor outcomes because no one is coordinating the care and focused on the care. We have to try to get around this very fragmented system and organize the care in a much more systematic and logical way.”
Bobbi Wager, RN, MSN, president of the American Association of Kidney Patients (AAKP), agreed that establishing integrated care management leads to better communication between patients and healthcare providers, which ultimately will lead to better patient outcomes and morbidity.
“In the United States, we lose millions of patients in the transition from Stage 3 to Stage 4 with such a low percentage of CKD patients making it to Stage 5 CKD. That is unacceptable for a country that is a leader in healthcare,” she said.
Establishing an ICM Program
According to DaVita’s Nissenson, the major goals of a disease management program are early identification of CKD patients and therapy to slow the progression of the disease; identification and management of CKD complications; identification and management of the comorbid conditions; and smooth transition to renal replacement therapy.
For ESRD patients you also need a program that focuses attention on avoidable hospitalizations as well as a multidisciplinary collaboration among physicians and participating caregivers.
