CKD: A national imperative
Thirty-seven million people in the United States have chronic kidney disease (CKD).¹ Yet nine out of 10 individuals with CKD don’t know they have it, in large part because symptoms often don’t present until the disease has progressed to a more advanced stage.¹
There is a recognized need for large-scale change across the kidney care continuum. Change is being proposed and implemented on many fronts, including a recent national policy directive to improve kidney care.
Many other efforts are underway by diverse stakeholders across the health system to improve CKD awareness, detection, risk prediction, patient-centered treatment choice, and benefit management and design.
OptumLabs and its partners are supporting key research initiatives aimed at helping change the treatment landscape for those with chronic kidney disease, including:
- Improving detection and early prevention of late-stage CKD and end-stage renal disease (ESRD) through a collaboration examining patient, provider and plan characteristics associated with unrecognized progression to late-stage CKD and ESRD.
- Developing quality measures to improve detection and monitoring of CKD among people with diabetes and hypertension.
- Fostering research outcome sharing, data knowledge and kidney policy education through an OptumLabs-led CKD Collaborative.
A federal policy directive
In July 2019, the White House issued an executive order directing the Department of Health and Human Services (HHS) to embark on multiple initiatives aimed at transforming care delivery for patients with CKD with the goal of reducing the number of Americans developing ESRD by 25% by 2030.²
The “Advancing American Kidney Health” order addressed key areas to prevent and better treat CKD:
Preventing disease progression
The best treatment for CKD is early intervention when the disease can be slowed or stopped.³ Since high blood pressure and diabetes are the two leading causes of CKD,1 managing these conditions can help prevent CKD.⁴
Yet, less than half of patients with these risk factors are appropriately screened and monitored for CKD.⁵ This suggests there is an overall need to increase awareness and promote screening in primary care settings, especially among those at highest risk.
Promoting organ donation and transplantation
If left untreated, CKD can progress through several stages and lead to ESRD, which requires dialysis or a kidney transplant for a patient to live.⁶
There is no cure for ESRD. In addition to the personal burden on patients’ lives, dialysis costs $88,000 a year under Medicare’s ESRD Quality Payment Program, about three-fold higher than the cost of a patient with CKD stages 4–5.⁷
Kidney transplantation is the best form of renal replacement therapy, and transplantation is considered the best treatment for ESRD.
For those who have already progressed to ESRD, a successful transplant reduces mortality by 50% or more, and doubles life expectancy when compared to dialysis-based therapies.⁸
A preemptive living donor transplant graft lasts twice as long (15–20 years) on average as a deceased donor graft (7–10 years) and comes with a tremendous reduction in overall medical expense, and increase in recipient quality of life by avoiding dialysis altogether.⁹
However, while about 100,000 Americans are waiting for a kidney transplant, only about 21,000 received one in 2018.⁵
The organ shortage has many causes. Among them are financial barriers for living kidney donors, and the fact that more than 3,500 kidneys are discarded each year due to selectivity standards and other logistical issues .6 10
Reform and alignment of multiple stakeholder incentives is needed to increase utilization of available organs and increase supply.
Changing the payment structure for ESRD care
Current payment policies for CKD and ESRD have resulted in financial incentives that may encourage patients to start dialysis earlier (instead of delay disease progression) and to choose in-center hemodialysis over home-based dialysis therapies.⁸
On the other hand, some studies show home dialysis therapies have been associated with improved quality of life, reduced costs and an improvement in patient survival.¹¹
The federal government is not the only organization working on improving policies to help people with CKD have access to care that will increase their quality of life.
The Coalition for Kidney Health
The National Kidney Foundation (NKF), with OptumLabs as Steering Committee Member, have formed the Coalition for Kidney Health (CKH) to help fill a gap in the health care policy and advocacy landscape.
The coalition seeks to transform the landscape of care for CKD by increasing awareness; improving prevention, early identification, diagnosis and treatment to slow or stop CKD progression; and improving quality across the spectrum of CKD care.
The coalition plans to do this through two initiatives:
1. Developing a national kidney health strategy
Raising public awareness of CKD can be considered the first milestone in developing a national strategy. NKF and collaborators have joined together to create an awareness campaign, “Are You the 33%?”.
Launching in September 2020, the campaign will educate patients, providers and the public on the risk factors for kidney disease and encourage action.
2. Advancing high-quality coordinated care
The ideal spectrum of CKD care begins with earlier screening and detection of CKD. It also focuses on preventing and delaying progression, and managing complications and comorbidities through co-management of patients among family physicians, nephrologists and others.
One way the coalition is working to achieve this ideal spectrum is by enhancing existing Medicare benefits. Examples include improving the scope of the Kidney Disease Education benefit and the Medical Nutrition Therapy benefit.
OptumLabs role in improving kidney health
OptumLabs is working on several collaborative programs to advance high-quality, coordinated care for people with CKD:
Improve detection and early prevention
To improve detection and early prevention, OptumLabs is leveraging the integration of commercial, Medicare Advantage and linked electronic health record (EHR) data from the OptumLabs Data Warehouse (OLDW) with fee-for-service Medicare data.
OptumLabs will use this combined data to identify patient, provider and plan characteristics associated with unrecognized progression to late stage CKD and ESRD. This research project is supported by NKF and Optum.
Facilitate quality measure development
Though many organizations have proposed quality measures for CKD, few have been adopted, leaving a gap in quality measurement. OptumLabs is facilitating quality measure development through a grant to NKF as part of the AARP Quality Measure Innovation Grant Program.
In collaboration with AMGA, NCQA, Physician Consortium for Performance Improvement (PCPI) and the University of California, San Francisco, NKF is testing a performance measure in OLDW for an annual kidney health evaluation in adults with diabetes, an important risk factor for kidney disease.¹²
Currently, the only way to diagnose CKD is through two specific tests:
- A blood test for creatinine, which is used to estimate kidney function, called estimated glomerular filtration rate (eGFR).
- A urine test called albumin-to-creatinine ratio (uACR) to look for evidence of kidney damage by checking for albumin, a protein that can pass into the urine when the kidneys are damaged.¹³
While testing rates for eGFR are good, only about half of adults with diabetes received an ACR test in 2018.¹⁴
Increasing testing rates for both measures is important to assist with early detection and prediction of patient risk levels for CKD. The measure will help track progression of the disease over time and support prevention and CKD progression.
Foster research outcome sharing, data knowledge and kidney policy education
OptumLabs partner researchers are involved in 10 active or completed projects across the continuum of kidney care. They are sharing insights from their work through the OptumLabs CKD Research Collaborative.
The collaborative enables AMGA, Mayo Clinic, HHS, Johns Hopkins, NCQA, NKF, Optum, UC Health and others to share results from their research projects, discuss approaches to data analysis and enable stakeholders to educate the group on CKD care and policy-oriented conversations.
Projects include research on home-based dialysis and conservative care choices, preemptive transplantation, identifying disparities in ambulatory kidney care delivery, and integrating atherosclerotic cardiovascular disease risk prediction into CKD care delivery.
The efforts underway by OptumLabs and its partners are highly synergistic with the national policy directives aimed at better outcomes and more patient-centered, cost-efficient solutions.
With this momentum on so many fronts, we’re collectively poised to make transformative changes on behalf of the 37 million patients with CKD.
- Chronic Kidney Disease in the United States, 2019. Centers for Disease Control and Prevention. Published March 11, 2019.
- Executive Order on Advancing American Kidney Health. The White House. Published July 10, 2019.
- Chronic Kidney Disease Tests & Diagnosis. National Institute of Diabetes and Digestive and Kidney Disease. Published October 2016.
- Saunders MR, Snyder A, Chin MH, et al. Health literacy not associated with chronic kidney disease awareness. Health Lit Res Pract. 2017 Jul;1(3):e117-e127.
- United States Renal Data System. 2018 Annual Data Report. Published 2018
- Kidney Disease: The Basics. National Kidney Foundation. Published 2019.
- Berns JS, Saffer TL, Li E. Addressing financial disincentives to improve CKD care. J Am Soc Nephrol. 2019 Nov;29(11):2610-2612.
- Gaston RS. Improving long-term outcomes in kidney transplantation: Towards a new paradigm of post-transplant care in the United States. Trans Am ClinClimatol Assoc. 2016;127:350-361.
- The Benefits of Kidney Transplant versus Dialysis. Beth Israel Deaconess Medical Center. Published 2020.
- Mohan S, Chiles MC, Patzer RE, et al. Factors leading to the discard of deceased donor kidneys in the United States. Kidney Int. 2018 Jul;94(1):187-198.
- Vinson AJ, Perl J, Tennankore KK. Survival comparisons of home dialysis versus in-center hemodialysis: A narrative review. Can J Kidney Health Dis. 2019 Jul 13;6.
- Kidney health evaluation measure. National Kidney Foundation. Published 2019.
- Quick Reference on UACR & GFR. National Institute of Diabetes and Digestive and Kidney Diseases. Published March 2012.
- Frequency of Testing for Albuminuria Is Low in Clinical Practice. Centers for Disease Control and Prevention. Published January 2020.
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