Practical Leadership in Cardiovascular Disease: The Chronic Kidney Disease Example
Chronic kidney disease (CKD) is extremely dangerous and one in seven adult Americans have it. That fraction is increasing. For patients with diabetes it is one in three and with hypertension it is one in five. There are very few conditions that are a greater threat. The average age at entry into the Steno-2 trial was 55 years. These patients had type 2 diabetes and chronic kidney disease. By age sixty-eight, half of them were dead and they had suffered an average of two cardiovascular events each. Here is the really crazy thing. Only one out of ten Americans with CKD even know they have it. They have not been diagnosed, or they have not been informed of this diagnosis. That means they are highly unlikely to be taking the measures needed to stay alive and off dialysis.
Making the diagnosis could not be easier and current standards of care mandate urine and blood testing annually. If there is protein in the urine or the kidney function on the blood test is 60mm/min or less, then the the patient has chronic kidney disease. What could be easier than that? Why is it that patients with diabetes and hypertension don’t even know that they have this very serious threat?
It is a systems problem and a leadership problem. It is not just the poor and uneducated that don’t know. It is everyone. In usual care, it is all on the doctor to make sure patients receive everything they need. Patients with diabetes are very complicated. They are on multiple medications and if they have CKD they are much more likely to experience other complications. The doctor can’t manage it all in her 7 minute office visit. Primary care doctors frequently refer diabetic patients to endocrinologists, cardiologists, etc. Care is fragmented. The primary care provider may think the endocrinologist or cardiologist did the tests and may not get the result. Communication and information exchange between providers is poor and the right hand often does not know what the left hand is doing. The end result, only ten percent of patients with CKD know they have it.
Good healthcare leaders can easily increase the percentage of patients who know they have CKD to 90%. The primary care chronic cardiometabolic condition team can provide most care for patients with diabetes or hypertension. Reduce care fragmentation. Treat these patients yourself. Keep them in your practice. Establish a team. Establish a registry or population health tool with a spot to document the blood and urine test. Assign a medical assistant to make certain that every patient with diabetes and/or hypertension has the appropriate blood and urine test every year and that the result is documented in the registry. If the tests indicate chronic kidney disease, then she notifies the provider so that she can put the diagnosis in the chart, notify the patient, and begin optimal medical therapy (OMT). Every patient gets the appropriate testing, the important diagnoses are made, and the best practice treatment begun—every time.
OMT prolongs life and delays cardiovascular events by 8 years in these patients. Patients on OMT have one fourth as many heart attacks, one fifth as many strokes, and one sixth as many go on dialysis compared with usual care. Patients on OMT are 70% less likely to be hospitalized for heart failure and all those benefits cost less than usual care. Almost no one wants to die young, be hospitalized, have a stroke, or go on dialysis. Most want a longer, healthier life and the CKD diagnosis is an opportunity to increase patient participation in their care.
Many of you reading this are leaders in your community. We can bring these benefits even to rural and underserved populations now. Let’s get started!