Contributor: Physician-Health Plan Collaboration Is Key to Early Identification of Chronic Kidney Disease

By the CDC’s estimate, 15% of adults in the United States are currently living with chronic kidney disease (CKD). This encompasses about 37 million people, yet, by that same estimate, as many as 9 in 10 adults with CKD do not know they have it, as CKD is often “silent” in its early stages.1 For many, symptoms don’t appear until the kidneys are badly damaged or their kidney disease is advanced. Without screenings, these patients may remain under or improperly diagnosed until their condition has worsened significantly, negatively impacting their treatment and care.

Rehan Waheed, MD

Guidelines from the National Kidney Foundation recommend 2 tests to screen for, diagnose, and manage CKD.² They include a serum blood test measuring creatinine with estimated glomerular filtration rate (eGFR) to evaluate kidney function and a Urine Albumin-Creatinine Ratio (uACR) test to evaluate kidney damage. Recent studies showed high levels of eGFR testing, but low levels of uACR testing, particularly among higher-risk patients with diabetes, suggesting physicians are selectively adhering to guideline recommendations.³

Yet, 1 study suggested that many patients at risk are not being screened at all during early stages, when treatment can reduce unfavorable outcomes, including requiring dialysis and transplant due to kidney failure. In fact, recent reports show prevention, recognition, and treatment strategies for CKD are greatly underutilized overall.⁴ Furthermore, data shows 1 in 4 patients ‘crash’ into dialysis therapy.⁵ Not only should these findings concern patients and physicians, but also health plans, self-insured employers, and other risk-bearing organizations, given the cost and patient care implications associated with severe CKD. As one example, treating Medicare beneficiaries for CKD cost over $87.2 billion in 2019.⁶

CKD and end-stage renal disease (ESRD) are massive expenditures, with most resources focusing on treatment after damage has already been done. Underscoring this, patients with ESRD qualify for coverage under CMS, yet require another form of insurance coverage prior to their diagnosis for eGFR and uACR testing.⁷ As such, funding innovative work upstream with regards to education, prevention, targeted interventions, and testing should lead to lowering costs over time with improved outcomes. With more testing, prediction of disease progression, and early intervention measures taken, communities can invest in their populations to also lower the risks of many other diseases.

Taking steps to improve an at-risk patient’s health before drastic measures like dialysis or transplant are necessary is important in providing the best care. While this may lead to a higher upfront investment, over time, prioritizing these prevention-focused strategies will ultimately create cost savings as conditions like ESRD, and others that may come as a complication of CKD, are limited. The question is, what should the medical community do differently to close gaps in screening to diagnose more patients in the early and more easily treatable stages of CKD?

First, utilizing population management tools to help identify patients early on can allow for intervention in the beginning stages of disease progression, helping to close gaps in care. Based on historical data, new at-risk members can be found and receive intervention like referrals, additional testing, and case management earlier. Collaborating with health plans to find hidden disease and risk-stratify patient populations can also be beneficial, and allows for providers and partners to leverage data and analytics to identify the patients at highest-risk for CKD for both early patient outreach and to arm physicians with vital educational content. In this way, health plans can take a proactive approach to determine the risk of new patients, rather than waiting for the next claim, which could delay care by many months.

For those patients that will need renal replacement therapies, or dialysis, certain tools can help predict timing to allow for peritoneal, instead of catheter, dialysis starts and lead time for transplant consideration. By predicting which individuals are most likely to require these therapies as soon as in the next 12 months, health plans can better organize resource allocation to smooth or delay the transition for the patient. Utilizing these tools can ultimately lead to better quality of life for each patient, and a possible reduction in the costs of care. Additionally, we cannot undercut the importance of meeting patients where they are using low-friction, patient engagement programs to help patients understand and manage their CKD risk, as well as provide education and guidance in making lifestyle modifications to limit CKD progression.

Taking a prevention-focused approach with at-risk patients, including those with diabetes and high blood pressure, is the best tool we have to deliver better care. However, the progression of the COVID-19 pandemic has made ensuring individuals receive the care they need challenging. Many patients are only now getting back to care after delaying in-person medical visits for fear of COVID-19 contagion. We have seen the effects these delayed appointments can cause: cancer diagnoses declined sharply during the pandemic.⁸ and other chronic conditions like CKD may follow the same trend. When early detection is so vital to treating these conditions, delayed care can be problematic.

Physicians and health plans can and should work together on this important issue. Access to screenings and educational tools can drastically improve outcomes for the patients most in need of intervention. Lack of adherence to guidelines can cause longstanding effects for patient populations, so it is critical that physicians take advantage of the tools at their disposal to ensure these tests are utilized as recommended.

Dr. Waheed joined Quest Diagnostics as Senior Medical Director and Chief Medical Informatics Officer in 2021. In his leadership role at the critical intersection of medicine, informatics, and business, he oversees clinical expertise for Quest’s healthcare analytics solutions while also championing important initiatives to advance analytics in public health. Dr. Waheed is a proponent of value-based, patient-centered healthcare leveraging health information technology, and is board-certified in Internal Medicine.

Reference

1. Chronic kidney disease in the United States, 2021. CDC. Updated March 4, 2021. Accessed May 17, 2022. https://www.cdc.gov/kidneydisease/publications-resources/ckd-national-facts.html
2. Quick reference guide on kidney disease screening. National Kidney Foundation. Accessed May 17, 2022. https://www.kidney.org/kidneydisease/siemens_hcp_quickreference#:~:text=Therefore%2C%20it%20is%20recommended%20that,in%20a%20spot%20urine%20sample
3. Folkerts K, Petruski-Ivleva N, Comerford E, et al. (2021). Adherence to chronic kidney disease screening guidelines among patients with type 2 diabetes in a US administrative claims database. Mayo Clin Proc. 2021;96(4):975-986. doi:10.1016/j.mayocp.2020.07.037
4. Chronic kidney disease in focus: Gaps in CKD diagnosis and care. Medpage Today. January 14, 2020. Accessed May 17, 2022. https://www.medpagetoday.com/resource-centers/chronic-kidney-disease-focus/gaps-ckd-diagnosis-and-care/2742
5. Molnar AO, Hiremath S, Brown PA, et al. Risk factors for unplanned and crash dialysis starts: a protocol for a systematic review and meta-analysis. Syst Rev. 2016;5:117. doi:10.1186/s13643-016-0297-2
6. Chronic kidney disease basics. CDC. Updated February 22, 2022. Accessed May 17, 2022. https://www.cdc.gov/kidneydisease/basics.html#:~:text=In%20the%20United%20States%2C%20diabetes,cost%20an%20additional%20%2437.3%20billion.
7. End-stage renal disease (ESRD). CMS. Updated December 1, 2021. Accessed May 17, 2022. https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Coordination-of-Benefits-and-Recovery-Overview/End-Stage-Renal-Disease-ESRD/ESRD
8. Kaufman HW, Chen Z, Niles JK, et al. Changes in newly identified cancer among US patients from before COVID-19 through the first full year of the pandemic. JAMA Netw Open. 2021;4(8):e2125681. doi:10.1001/jamanetworkopen.2021.25681