Case Study: 6 Months of Empowered CKD Management Results
Over the past year, the Empowered Kidney Care team has been shifting its focus from end stage renal disease (ESRD) to early-stage chronic kidney disease (CKD). By moving “upstream,” we can help preserve kidney function and prevent patients from having to go on dialysis.
Now, after six months at the University of Texas Health Science Center in San Antonio, Texas, Dr. Richard Gibney has six months of real-time data, demonstrating the results of empowered CKD management.
“The results are dramatically better than I ever thought. This is a game changer,” reports Dr. Gibney. “In six months, we haven’t put a single CKD patient on dialysis, and that’s a radical departure of what we’ve done before.”
Although the timeline and numbers are relatively small, the team is hopeful that their efforts provide a strong foundation for an empowered kidney care model. The UT Health Science Center serves some of the most marginalized and under-supported people in the San Antonio community, and yet, this vulnerable population is doing better than patients who have more resources and education.
What’s the difference? Patient empowerment.
“We’re doing something no one else is doing,” says Dr. Gibney.
A focus on preserving kidney function
Historically, nephrology focuses on dialysis and ESRD, but the Empowered Kidney Care team is turning that model on its head, moving upstream to help patients with CKD.
Dr. Gibney’s team prioritizes the following elements to manage CKD and preserve kidney function:
- Identify and communicate with patients and providers: Up to 92% of CKD 1-3 patients are unaware that they have kidney disease[i], and up to 80% of CKD patients do not receive proper testing[ii]. Kidney disease management begins with identifying and communicating with patients whose lab work shows a possible decrease in function.
- Manage hypertension and diabetes: High blood pressure and diabetes are the main contributing factors to kidney disease. In addition to diet and lifestyle changes, patients are prescribed important medications, including new SGLT-2 inhibitors.
- Empower patients to take care of their own health: Coach and train patients to take control of their health with hope and optimism.
- Build a collaborative healthcare team: Ensure consistent messaging between doctors and patients (align PCP, diabetes, cardiac, renal). Expand medical team to include MD, RN, and MA with dietary, social worker, and pharmacist support. Include patients in decision-making process as the most important member of medical team
- Manage high-risk medications for CKD patients: Avoid or modify dose of common medications like NSAIDs (Ibuprofen) and replace with safe alternatives wherever possible.
“70% of our new patients with CKD are diabetic… that’s where I’m putting my money. We’ve got to attack that problem and get the numbers down. That’s how we start to make progress.”Dr. Richard Gibney
Patient empowerment “homework”
True empowerment is a lifelong process, but it all starts with a few simple steps. Each patient is invited to bring three things with them as “homework” for every office visit.
- Health Data: Patients track and bring their own data (blood pressure, blood sugar, weight). They must have their own devices and know how to use them.
- Medications: Patients bring their medication bottles to each visit so they can discuss WHAT, HOW, and WHY they are taking them.
- Patient Advocate: Patients bring a close friend or family member for love and support.
“The patients actually love their homework, which is fascinating!” explains Dr. Gibney. “It’s a fabulous communication tool to the patients’ families. “I haven’t had anybody say they don’t want to be involved in their care.”
“When I started, there were zero patient advocates… now around 90% come in with an advocate—typically a daughter or wife. They have somebody else who knows what’s going on, and that’s very powerful.”
Over a six-month initial period, Dr. Gibney worked with 288 patients over 425 office visits. The majority of these patients (70%) were diagnosed with early-stage CKD 1-3 and the remainder (30%) diagnosed with CKD 4-5.
In order to preserve kidney function, the care team prioritized proactive medications and patient empowerment.
- Ace/ARB Prescribed: 132 (45%)
- SGLT-2 Prescribed: 100 (35%)
- Fully Empowered Patients: 70 (24%)
(See the CKD Empowerment Checklist for a definition of patient empowerment)
Additional health and care data included:
- Conservative Care: 11 (3%)
- Edema/CHF: 45 (15%)
- Proteinuria (UP/UC)>500 mg: 34 (12%)
- Diabetic Patients: 196 (68%)
- Hypertension Patients: 247 (85%)
Over the first six-month period, the care team succeeded in their goal to preserve function and keep CKD patients from progressing to start dialysis.
A stark reminder of the stakes
Although this journey was overwhelmingly positive, it was not without its low points. During the first six months, Dr. Gibney accepted two new patients with ESRD who had to begin dialysis right away.
One was sent by emergency room after crashing with unanticipated kidney failure; the other came with a previous history of CKD mismanagement. Both serve as painful reminders of the urgent need to catch and manage CKD as soon as possible.
Dr. Gibney explains: “that second patient arrived with a GFR of 8 or 9, and he had never been prescribed any medications. At that point it’s game over. He’s got to begin dialysis… What would have happened if we could have gone upstream a year or two earlier when he had a GFR of 60? He wouldn’t be on dialysis today. Unfortunately, this patient was totally mismanaged by his medical team.”
For Dr. Gibney and the Empowered Kidney Care team, this passive approach is completely unacceptable.
“That man experienced old-school mentality of ‘good luck buddy.’” Says Dr. Gibney. “That culture has got to change.”
The future of Empowered Kidney Care
After setting the bar for continued work with CKD, the EKC team is looking forward to expanding empowered principles to other aspects of kidney disease, including social determinants of health.
“We’re continuing to build our team with a new full time social worker, dietician, pharmacist,” shares Dr. Gibney. “They are going to help provide affordable medications, tools, and knowledge so patients can focus on health.
“We can do a lot better when we have operational systems that empower patients to take control over their own care,” explains Dr. Ken Boren. “The impact on the patients is tremendous. They have something to do; they’re not just waiting to go on dialysis.”
Ultimately, the goal is to dramatically reduce the number of patients going on dialysis, but if and when patients do end up with kidney failure, empowered healthcare practices can help them too.
“What could happen if we expand this program to the whole spectrum of CKD management, including home dialysis and transplant?” asks Dr. Joseph Lee. “These are the kinds of things that have huge incidental benefits, keeping patients at work, limiting the burden on their families, and reducing the strain on our healthcare system.”
Join the Empowered Kidney Care Movement!
Are you interested in implementing empowered kidney care practices at your own clinic? We want to empower YOU, and we want to know how things are going. Don’t hesitate to contact us or take advantage of our CKD empowerment resources:
[i] United States Renal Data Systems (USRDS)
[ii] National Kidney Foundation (NKF)