As Kidney Function Declines, Risks and Costs Increase: OMT Increases Kidney Function
Yesterday’s post showed how costs and risks go up as kidney function decreases. Just prior to the availability of optimal medical therapy (OMT), this was the consensus view: “Rates of progression of CKD (chronic kidney disease) may differ; rarely, patients may even improve. In general, however, the condition of persons with CKD will deteriorate. The progressive course of CKD is a function of many factors…” In usual care of patients with diabetes and chronic kidney disease, kidney function decline is relentless once it starts. That changed in 2008, when the landmark Steno-2 trial showed that six times as many patients went on to dialysis in usual care compared with those on OMT. Changes in kidney function are a good marker for risk and cost.
In 2007, I moved to a very large medical group in extreme northeastern Tennessee—Appalachia. I worked with a team of three pharmacists in an advanced medical home for cardiovascular and related conditions. One group of patients had high-risk diabetes or hypertension and they worked for a large self-insured employer. The spreadsheet above represents a mixed population of patients with Medicare and commercial insurance. This is a screenshot from an excel file that included 81 patients with diabetes and CKD. These were patients in my own panel. I worked with them in one on one visits and so I was absolutely certain that they were on OMT. On average, kidney function as measured by the estimated glomerular filtration rate (eGFR) improved by 7.5 milliliters per minute. That is not relentless deterioration. OMT increased kidney function. I could not get the entire file on the page, but look at some of the numbers. Check out patient seven, he was almost in stage 4 CKD and improved to stage 2. There we very few hospitalizations in this group and the data means we were replicating the outcomes seen in Steno-2. We were slowing progression to dialysis. By extension, we were reducing heart attacks, strokes, and amputations.
How did I do it? The targets for blood pressure, diabetes, and cholesterol were 130/80, HbA1c of 7, and LDL of 70 and on a statin respectively. I used lisinopril or losartan, amlodipine, hydrochlorothiazide, and spironolactone or eplerenone for blood pressure. I started with 12.5 mg of spironolactone or eplerenone every other day in this population and I watched the kidney function and potassium carefully. I used reduced dose metformin for diabetes as long as the eGFR was above 30. LDL was generally well-controlled and I worked hard to be sure everyone was on a statin. No one went to the hospital as a complication of this treatment.
Dr. David Carmouche has done this same work with the same results. I went to work for him when he became the chief medical officer of a large insurance company. The first thing he asked me to do was to talk to the physician leader of The Family Doctors, a 15-provider primary care group. They were already known to be a progressive group. Dr. Hamic and I went to lunch and we discussed optimal medical therapy and the systems and protocols needed to produce the product. Two weeks later he called and said he wanted to proceed. He and two other doctors would start. Within 6 months, they were performing at a very high level. They presented the results to the rest of their colleagues, and they were the top performing group in the state most of the years that followed. Dr. Hamic talked with his friend, Dr Clint Wilson and he quickly became a high performer and leader. I worked with Dr Nick Heinen who went on to found a work-site clinic company, Vestra Health, that does a great job with OMT. The systems and science required to consistently produce OMT to slow chronic kidney disease are transmissible and scalable. I am still in touch with Drs Hamic, Heinen, and Wilson and they are reading most of these posts.
We can begin to replicate this work in your organization soon. You can make a big difference in improving health and reducing cost. Let’s get started! wbestermann@congruityhealth.com