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Integrating CKD Into US Primary Care: Bridging the Knowledge and Implementation Gaps
Joseph A Vassalotti1,2, Suelyn C Boucree3
1Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
Kidney International Reports
|March 8, 2022
Summary
Chronic kidney disease (CKD) affects millions, increasing cardiovascular risks. A coordinated care approach with integrated systems and population health strategies is vital for effective CKD management and reducing adverse outcomes.
Area of Science:
- Nephrology
- Public Health
- Health Systems Management
Background:
- Chronic kidney disease (CKD) impacts 37 million US adults, leading to high cardiovascular event rates, kidney failure, and mortality.
- Primary care screening for CKD using estimated glomerular filtration rate (eGFR) and urine albumin-creatinine ratio (uACR) should target high-risk conditions like diabetes, hypertension, and cardiovascular disease.
- CKD diagnosis necessitates improvements in patient awareness, engagement, and evidence-based intervention implementation.
Purpose of the Study:
- To outline a comprehensive CKD population health strategy for primary care.
- To address challenges in individualized CKD care due to disease heterogeneity.
- To emphasize the need for coordinated, interdisciplinary care and integrated health systems for optimal CKD management.
Main Methods:
- Focus on primary care case finding using eGFR and uACR for at-risk populations.
- Advocating for a coordinated care model involving interdisciplinary teams.
- Implementing integrated systems with registry functions, clinical decision support, and quality improvement initiatives.
- Adopting the Race-free 2021 CKD-EPI eGFR reporting recommendations.
Main Results:
- Integrated systems can support primary clinicians with essential CKD management tools.
- A population health strategy can bridge primary care education and implementation gaps.
- Registry functions and data monitoring are crucial for understanding CKD burden and intervention effectiveness.
- Collaboration with nephrology, laboratory, and health equity leaders is key for population health design.
Conclusions:
- A coordinated, system-integrated approach is essential for effective CKD management in primary care.
- Population health strategies, supported by integrated systems and data monitoring, can improve CKD outcomes.
- Implementing updated eGFR reporting recommendations is vital for advancing CKD population health efforts.
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