Transcript Traditional vs. Behavioral Economics

A Perspective on CKD Management
Mony Fraer
May 2014
Topics
1. CKD - Model of a Chronic Disease
2. Chronic disease burdens
3. Multidisciplinary Care
4. Patient engagement
5. The UK model
CKD - Model of a Chronic Disease
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> 13 % adults with CKD
> 15 million with stage 3 CKD
Prevalence of CKD: 5% /year growth
patients are complex and at high-medical risk (risk of reduced
all-cause mortality, CVD, infection, AKI)
• risk of death from CVD > progression to ESRD
• CV risk reduction - management of CKD/slowing progression
Financial Burdens ad Barriers
• before starting dialysis, majority of costs are from
hospitalizations (6 mo. before initiation of dialysis)
• month of initiation of dialysis: $25,000 - $35,000.
• annual cost: CKD ($28,000 - $65,000 ) and ESRD ($85,000 )
• annual cost: $5,000 for CHF and $10,000 for DM
• Government/payers are demanding value ( = quality/cost)
• reimbursement models that do not align incentives for all
involved
The Problem
Management of advanced CKD is suboptimal (irrespective of
whether patients are treated by nephrologists or nonnephrologists)
Causes
• late diagnosis of CKD
• lack of awareness - magnitude and significance of CKD
• fragmentation of care with (multiple caregivers in myriad
settings)
• late referral to nephrology
• insufficient use of therapies to slow CKD progression
• insufficient treatment of complications/comorbidities
• abrupt transition to renal replacement therapy
Causes
• solitary physician visits - not an appropriate care model
• CKD disparities (racial, ethnic, socio-economic)
ESRD patients
• fragmented care
• lack of attention to comorbid conditions
• failure to provide preventative services
Aims
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Early identification of CKD and its complications
Delay/prevent progression of CKD and need for RRT:
Management of the comorbid conditions
Smoothing the transition to ESRD and RRT
Attention to avoidable hospitalizations
Nephrologists
• > 2000 CKD patients/nephrologist
• usually nonprogressive disease and not necessarily requiring
specialized care
• no formal involvement of the PCP beyond the traditional
communication of a clinic note
Primary Care Physicians
• limited time to deliver appropriate/recommended chronic
disease mgmt. (CDM) in addition to diagnosing new problems
and providing preventive care
• large number of MD’s - not aware of KDOQI guidelines
• overlap between DM, CVD and CKD, it is possible that
physicians prioritize treatment for DM and CVD (link between
these and CKD)
Patients as Self-managers
• Complex treatment regimens
• Monitor their conditions
• Make lifestyle changes
• Make decisions about when to seek professional care and when
they can handle a problem on their own
• High level of knowledge, skill, and confidence
Education
Patient awareness, education, empowerment in decision making
and repeated interactions with the care team
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dietary counseling
medication management
ongoing education about RRT/conservative care
about the condition
other behaviors
National Kidney Foundation tools: www.kidney.org
Patient Engagement
• Assessing depression
• Patient activation measures (patient knowledge, skill, and
confidence for self-management)
• Medication adherence
• Self-efficacy
• Disease knowledge
https://uiowa.qualtrics.com/SE/?SID=SV_cN2Pd3PhvmktuER
Questions to Answer
1. How to leverage the expertise of nephrologists
2. At which stage of CKD should patients be referred to a
nephrologist
3. What is the level of expertise that can be expected of PCP’s in
the mgmt. of CKD
4. Best way to involve allied health professionals in
multidisciplinary CKD care
5. Is there a point, before ESRD, at which the nephrologist
should assume primary care of a patient with CKD
Multidisciplinary Care
Elements of a CKD model of care:
• Early identification of patients
• Longitudinal protocolized follow-up (as opposed to episodic
care)
• Interventions to delay progression
• Timely preparation for RRT/or planning for conservative care
The Team
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Nurses
PCP’s
Nephrologists
Dietitians
Cardiologists, endocrinologists, vascular surgeons, transplant
physicians
• Other: physiotherapists, social workers, and psychologists
Implementation of Care Models
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data management tools
education programs (for team members)
communication tools
formalized protocols
guideline-driven approach
restructuring of practices to multidisciplinary teams
computerized decision-making support
Pharmacists
Navigator/Case manager
• changes in patient status - appropriate team members are
involved at the appropriate time for specific patients.
• help the patient and their family understand where they are
in the spectrum of disease
More Prominent Involvement of PCP’s
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stable kidney function/slowly progressive
issues of reversibility have been addressed
measures implemented to slow progression
comorbidities and CV risk factors have been addressed
had dietary counseling
More Prominent Involvement of PCP’s
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have made modality decisions and have a plan for the start of RRT
on all appropriate medications
reasonable achievement of target BP
stabilization of laboratory parameters associated with CKD
The ability of the PCP to liaise with the MDC team must be effortless
Results
integrated care (comprehensive, team-based, MDC for CKD and
comorbidities)
vs.
usual care (PCP management using outside nephrology
consultation) :
- slower decline in GFR over time
- lower percentage of patients initiating dialysis
Through the Looking Glass: A New Perspective
on Population Management
https://www.uhc.edu/cps/rde/xchg/wwwuhc/hs.xsl/56693.htm
The UK Model
• Closed managed care system funded by the government and
paid for by general taxation
• Among the lowest health care spenders of OECD
• All practices are fully computerized and >97% receive lab results
electronically (will detect CKD at the primary care level)
The UK Model
• Strategic planning for kidney services (public health problem)primary care priority
- guidelines selecting patients for referral to specialized care
- quality outcomes framework system rewards physicians for
tracking specific evidence-based indicators in CKD
- specialized multidisciplinary clinics
The UK Model
In the first 2 y > 40% of the expected CKD 3 to 5 population registered
in primary care
Can we do it?
• Assessing depression, patient knowledge, skill, and confidence for
self-management, medication adherence
• Referral charts (decision making trees) for primary care
• Multidisciplinary clinics
• Incentives (insurers, employers)
• UK type level of integration and decision making