Enhancing PCP-Nephrologist Co-Management for CKD: Leveraging Population Health Management and Learning Health System for Scalable Solutions

About This Grant

Abstract Chronic kidney disease (CKD) afflicts 37 million Americans and leads to increased morbidity, mortality, and healthcare costs. With emerging CKD guidelines and highly effective new therapeutics, there is an urgent call for scalable and resource-efficient population-level approaches to optimize CKD care. The overarching goal of this proposal is to evaluate clinical- and cost-effectiveness of a multifaceted population health management (PHM) implementation approach that facilitates PCP and nephrology co-management to deliver evidence-based CKD care. Using a learning health system approach, we developed and implemented Kidney-Care, which is a novel, electronic-health record (EHR) based, multi-faceted PHM intervention. It builds on successful elements of our prior Kidney- Coordinated HeAlth Management Partnership (K-CHAMP) program, which included centralized, remotely delivered intervention bundle with timely nephrology E-consults, pharmacist-led medication management, nurse-led standardized patient education, and PCP academic detailing. In the enhanced K-Care program, we targeted PCP’s therapeutic inertia and unfamiliarity with new guidelines through reinforced academic detailing and experiential case-based learning through E-consults. We targeted patient behavior change through education on CKD prioritization and importance of newer medications, hired a renal social worker to address medication affordability and social risk factors, and expanded our team with a renal dietitian and renal-palliative clinicians. K-Care program scaled up the intervention to 101 PCP practices within our health system, providing access to ~ 24% rural-living patients. The proposed study provides a unique timely opportunity to answer the following specific aims: 1) To compare the long-term clinical effectiveness of a multifaceted CKD PHM intervention versus usual care on renal and cardiovascular (CV) outcomes among patients with CKD at moderate-high risk of ESKD; 2) To evaluate effectiveness of CKD PHM intervention in improving guideline-concordant care compared to usual care; 3) To assess the cost-effectiveness of CKD PHM intervention compared to usual care. Using EHR data, we will conduct a target trial emulation to determine the 5-year intent-to-treat effect of the K-Care program (n~3000) compared to contemporary usual care using inverse probability of treatment weighted marginal structural models. Our primary composite outcome is CKD progression (≥ 40% decline in eGFR or ESKD) or CV death. Secondary outcomes include hospitalization for heart failure or CV death, hospitalization for any cause, death from any cause, CKD progression, CV death, and major adverse CV events. We will also evaluate guideline-concordant care outcomes (hypertension and glycemic control, albuminuria testing, medication use) and incremental cost effectiveness ratio per quality-adjusted life-year gained. This proposal aligns with value-based CKD goals outlined by Center for Medicare & Medicaid Services and the Advancing American Kidney Health Initiative.