Are PCPs the missing link in the fight against CKD?

For decades, chronic kidney disease (CKD) has received little attention until it’s time for a patient to begin dialysis. In fact, data from CMS shows that 92% of patients with CKD stage 1-3 are UNAWARE that they even have kidney problems.

“92% of patients with CKD stage 1-3 are unaware that they have kidney problems.”

Centers for Medicare and Medicaid Services

“This statistic is completely outrageous,” says Dr. Richard Gibney, president of Empowered Kidney Care. “We can do better. Waiting to address CKD until it’s time for dialysis is like waiting to address circulation issues until gangrene sets in and it’s time to amputate a limb. There are simple things we should be doing right now to keep the problems from getting any worse.”

Are we missing the big picture problem?

For over 40 years, Dr. Gibney practiced nephrology in Waco, Texas. In 2014, he led a successful transformation of 11 dialysis units to an empowered self-care model. By creating a collaborative environment that gave patients control over their own care, he saw dramatic improvements in outcomes for end stage renal disease (ESRD) patients — cutting mortality and hospitalization rates in half.

Empowered self-dialysis led to monumental improvements in ESRD outcomes, but more recently, Dr. Gibney began to wonder how similar empowered principals could stop patients from needing dialysis in the first place.

“What if we’ve got it all wrong? What if the solution to this problem is further upstream?”

Dr. Richard Gibney

As a kidney disease specialist, Dr. Gibney typically didn’t see patients until their disease had progressed to advanced CKD. By that time, prevention is no longer an option. Transplant or hemodialysis are the only ways to support kidney failure.

Going upstream to solve CKD

In healthcare circles, you will sometimes hear a story about going upstream in a river. Author Saul Alinsky tells the story this way in Shelden & Macallair:

Imagine a large river with a high waterfall. At the bottom of this waterfall hundreds of people are working frantically trying to save those who have fallen into the river and have fallen down the waterfall, many of them drowning. As the people along the shore are trying to rescue as many as possible one individual looks up and sees a seemingly never-ending stream of people falling down the waterfall and begins to run upstream. One of other rescuers hollers, “Where are you going? There are so many people that need help here.” To which the man replied, “I’m going upstream to find out why so many people are falling into the river.”

Saul Alinksky, Shelden & Macallair

So, if nephrologists are already consumed with saving the advanced CKD patients already “drowning” in the river, who can go upstream to stop people from falling in in the first place?

Are PCPs the answer?

The stunning thing about CMS’s statistics on CKD awareness is that test data was already available. Indicators of kidney decline are easily traceable in existing standard lab work, so why wasn’t anyone telling the patients? Why were 92% kept in the dark?

“This gap in communication and education means we have a huge opportunity!” explains Dr. Gibney. Who can stand in this gap? We need someone to consistently be in the right place at the right time.

“When it comes to preventing CKD, PCPs might just be the most powerful people in the room.”

Dr. Richard Gibney

PCPs are in a unique position because unlike specialists, they are already engaged in a long-term relationship with the patient. They are like the quarterback of the healthcare system — parsing information, coordinating players, and executing plays for the patient.

If primary care physicians can catch early warning signs, they can then help educate the patient and walk alongside them to make healthy lifestyle and medication choices that prevent further kidney decline.

If the entire primary care team can collaborate together to empower CKD patients, they could essentially cut off the problem at its source, saving countless lives and preventing millions of Americans from ever having to start dialysis.

Lessons learned from Project ECHO and hepatitis C

We already have an excellent case study of how collaboration and empowerment can prevent and manage common diseases through the University of New Mexico’s Project ECHO.

The successful initiative followed a familiar story… It began in when Sanjeev Arora, M.D., a liver disease specialist was frustrated that he could only serve a small fraction of the hepatitis C patients who needed help in his state. Many of these patients were minorities, and unable to receive specialized care in rural areas and prisons.

In response, Dr. Arora created a free education model in 2003 in which he and other specialists could mentor primary care physicians around New Mexico. By providing knowledge, collaborative tools, and community, project ECHO was able to empower rural care centers and prisons to provide excellent specialized care and improve outcomes for hepatitis C patients.

Since then, Project ECHO has expanded to empower physicians dealing with a variety of common issues all around the world. Like hepatitis C, kidney disease is a relatively common problem with serious consequences if left untreated. Could collaborative empowered practice help advanced CKD all but disappear?

Early CKD detection and alert systems

Primary care physicians can first aid in the fight against CKD by closing the awareness gap around the disease. Many patients are already receiving baseline annual physicals and urinalysis. These existing tests provide enough data to recognize early warning signs, including blood pressure, albumen in the urine, and decreased Glomerular filtration rate (GFR).

Healthcare providers need to first create systems that identify kidney problems and alert patients and their healthcare teams.

“Another simple improvement is implementing medication reconciliation surveys,” Dr. Gibney explains. “We need to double check that our records accurately reflect the drugs a patient is prescribed. Often times they are on medications they shouldn’t be, or they are missing out on ones they should be taking.”

For example, it’s a common best practice to have CKD patients on an ACE or ARB medication to help preserve kidney function, but surveys reveal that 50% of patients are not.

More recently, new drugs like SGLT-2 inhibitors provide even more options to stabilize kidney function.

Embrace culture shift

Once kidney problems have been identified, the PCP is in an excellent position to build a relationship and trust with the patient, guiding them throughout their journey with CKD. This isn’t an overnight process, but requires a larger-scale culture shift to empower patients with the knowledge and tools they need:

1. Stories: Every relationship begins with active listening. Take the time to build relationships and trust by listening to your patients’ stories.
2. Awareness: Keep your patients and healthcare team in the loop. Make sure they are aware of potential issues and the options available to them.
3. Education: Knowledge is power. Coach your patients through lifestyle changes that can improve their condition. Teach them about warning signs that they should keep an eye on.
4. Control: Before you jump to fix your patients’ problems for them, ask yourself how the patient can be part of the solution. Give them dignity and respect of making their own decisions. Give them the knowledge and tools they need to take care of themselves.
5. Collaborate: Make the connections you need to form a complete healthcare team of medical specialists, social workers, and others. Only by collaborating together can we understand and affect the big-picture medical, emotional, mental, and social determinants of health.

Now is the time to make a change

Especially with recent healthcare policy changes like the Primary Care First Act, PCPs can take advantage of financial incentives for empowered practices.

Doctors can now participate in cost sharing plans and receive rewards for reducing hospitalizations, lowering mortality rates, and improving outcomes. Patients empowered with CKD knowledge and self-care tools, for example, are much less likely to need a kidney-related emergency room visit or hospitalization.

Time spent on patient education is also now billable, even when provided remotely via telehealth solutions.

Hemodialysis is unpleasant, time-consuming, and extremely expensive. By investing some strategic time and energy upstream, the healthcare community can make a major impact in treating common diseases like CKD. This means thousands of lives saved, a better experience for patients and providers, and significant savings for payers.

If you’d like to learn more about how your practice can prevent and manage CKD, don’t hesitate to reach out to us at Empowered Kidney Care.