Going Upstream: Coordination to Improve CKD Care

Abstract

Care coordination for patients with chronic kidney disease has been shown to be effective in improving outcomes and reducing costs. However, few patients with CKD benefit from this systematic management of their kidney disease and other medical conditions. As a result, outcomes for patients with kidney disease are not optimal, and their cost of care is increased. For those patients who transition to kidney failure treatment in the United States, the transition does not go as well as it could. The effectiveness of treatments to delay progression of kidney disease in contemporary clinical practice does not match the efficacy of these treatments in clinical trials. Conservative care for kidney disease, which should be an option for patients who are very old and very sick, is not considered often enough or seriously enough. Opportunities for early and even pre‐emptive transplantation are missed, as are opportunities for home dialysis. The process of dialysis access creation is rarely optimal. The consequence is care which is not as good as it could be, and much more expensive than it should be. We describe our initial efforts to implement care coordination for chronic kidney disease in routine clinical care and attempt to project some of the benefits to patients and the cost savings.

Chronic Kidney Disease: Exploring Value-Based Healthcare as a Potential Viable Solution

“…Care coordination for CKD patients has already been introduced in the US health system, and some pilots have also been introduced in the European setting [59,60]. The extension of such pilots to standard of care would entail to put patients in the centre of care provision and decision making, organizing across disciplines accordingly [60]. Moreover, such a set up would enable a care delivery system to follow a patient through the care cycle carefully to then measure and communicate meaningful outcomes and resource utilization accurately [28].…”

“…Additionally, as a CKD patient will be on different treatment options in their life, it is therefore crucial to determine the right modality for the right patient at the right time in the right location [46]. Care coordination for CKD patients has already been introduced in the US health system, and some pilots have also been introduced in the European setting [59,60]. The extension of such pilots to standard of care would entail to put patients in the centre of care provision and decision making, organizing across disciplines accordingly [60].…”

The Provider’s Role in Conservative Care and Advance Care Planning for Patients with ESRD

“…Although the latter is subject to lead time bias related to imprecisions with GFR estimation and difficulties with randomizing patients, additional evidence will help address these barriers consistently identified by providers, individualize discussions with patients and families, and facilitate decision making. Third, they show the need to promote a shared vision of ACP and interdisciplinary collaboration among different providers involved in caring for patients with advanced CKD (2).…”

“…Conservative care (CC), also known as conservative management, is being gradually recognized as a viable therapeutic alternative for patients with advanced CKD in the United States (1,2). The Renal Physician Association's clinical practice guideline on shared decision making in the appropriate initiation of and withdrawal from dialysis recommends to inform patients with stage 4 or 5 CKD and patients with ESRD about their prognosis and all treatment options, including CC (3).…”

UQ eSpace

“…Furthermore, patients under multidisciplinary care had significantly lower yearly healthcare costs, including costs associated with emergency and inpatient care (p<0.001). Patients in the control group also showed a comparatively faster annual eGFR decline (p=0.021) and a higher incidence of emergency initiation of renal replacement therapy (p=0.001).Finally,Johnson et al (2016) described the impact of Reach Kidney Care, a program which assigned nurse coordinators to approximately 3,000 CKD patients across 16 states of the US. The report functions as an ongoing discussion of progress towards particular treatment goals, however it does highlight anecdotal evidence of patients modifying their behaviour in ways that reduce their blood pressure and HbA1c scores upon being counselled about the possible imminence of dialysis.13 The potential for nephrologist referral to drive patient behavioural changes was also mentioned inFeest et al (1999).4.3 IMPACT OF CO-MORBIDITIES ON HOSPITALISATION AND EXPENDITUREAnother set of literature has sought to analyse the way in which CKD interacts with common comorbidities in determining cost behaviour, including whether the functional form of the relationship is additive or subject to interaction Smith et al (2004).…”