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7/31/2019 CKD_Payor
http://slidepdf.com/reader/full/ckdpayor 1/23
1
CKD Overview
Jerry Yee, MD
Paying Too Little or Too Little Prevention
2
OBJECTIVES
CKD description
Why Chronic Kidney Disease (CKD)is important to payors
Role of timely referral to nephrologists
Define the role of PCPs in CKD
HFHS/GHS roles in risk and therapeuticmanagement of CKD
3
“What is CKD?” QUIZ
IS CKD …
ESRD (ESKD)
Dialysis
Weak / failing kidneys
Proteinuria
“Cysts”
Small kidneys
One kidney
IS CKD …
Kidney transplant pt
Diabetic pt
Hypertensive pt
High CVD risk
Reduced kidneyfunction of any type
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4
Case Study
CC: Consult, high SCr .” HPI: 50 y.o. AAF
presents to ER withfatigue and leg swelling.She did not know that shehad kidney disease, butrecalls “proteinuria.”
T2DM ×10 yr HTN ×12 yr.
Cigarettes, 50 pk-yr. BUN 87 mg/dL
HCO3 17 mg/dLSCr 9.3 mg/dL (1997, 1.5)Hb 9.2 g/dL
Femoral HD catheter isplaced and HD is initiated.
AVF constructed and fails . 2nd HD catheter placed. 2 mos later, CRBSI
develops sepsis …
5
6
Summary
T2DM with proteinuria
Uncontrolled HTN
GFR not tracked
No referral
Failure to treat
Adherence issues
SCr solely monitored
Kidney situationdeemed not severeenough for Nephrology referral
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7
CKD: A Mortal Disorder
8
$tate of E$RD
Currently 325,000 Americans are ondialysis, at an annual per-patient cost of approximately $64 000.
Data from the National Kidney andUrologic Diseases InformationClearinghouse estimates an additional100,000 Americans are placed on dialysisevery year (~25% incident rate).
9
Rising ESRD PrevalenceMy Private Tsunami
Source: JL Xue, et al. J Am Soc Nephrol 12:2753–2758, 2001.
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ESRD and Etiology
Wayne Co.: ESRD prevalence is among highest of U.S. counties (453 per million)
72%
11
ESRD Expenditures from Paid Claims
Source: USRDS Coordinating Center, ADR 2005 (Allan Collins)
12
Medicare v EHGP
Medicare spending includes paid claims, estimated Medicare+ Choice costs, & estimated organacquisition costs. Non-Medicare spending includes estimates of costs for EGHP patients and for non-Medicare ESRD patients, & estimates of patient obligations.
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Patient Count$ & Co$t$ in DM, CHF, CKD and ESRD
Source: USRDS Coordinating Center, ADR 2005 (Allan Collins)
14
CKD CareEGHP Wor$e Than Medicare
15
ESRD Initiation$36,000 in 3 Months
$-
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
$14,000
$16,000
-24 -22 -20 -18 -16 -14 -12 -10 -8 -6 -4 -2 1 3 5
Month
P M P M , a l l o w a
b l e
Inpatient Outpatient Other Par t A Par t B
Source : St Peters W, et al. Kidney Int. 2000.
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17
Potential Co$t$ $aved by Implementing GFR
Source: Niagara Health Quality Coalition — BA Boissonault, President
2000
4500
7000
9500
12000
0 6 12 18 24 30 36
Time Since Initiation of Dialysis
M e a n M o n t h l y C o s t ( U S $ )
Hemodialysis
Peritoneal
18
US CKD Referral Pattern
Source: Stack AG. Am J Kidney Dis. 2003;41:310–318
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Reasons for Late Referral
Source: Survey — Allen Nissenson (2002)
20
Early Referral Difference
Infection
Late ReferralEarly Referral
21
CKD Is …
“Kidney” — lay term most understood and usedby constituents All other vague, ill-defined terms — ERI, CRI, CRF
Disease — implies pathophysiology and treatability
Anatomical disorders Stones
Cysts
Hypoplasia, agenesis
Functional abnormalities Proteinuria … persistent
Hematuria … non-urological
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22
CKD Is …
23
Proteinuria Prevalence(USA)
Adults with ProteinuriaAdults with Proteinuria
QuantitationTotal Adults
(millions)% of Adults
Increased UACR 20.2 11.7
Proteinuria18.3 10.6
Microalbuminuria1.9 1.1
24
Rationale for Proteinuria TherapyCV Outcomes Increase w/ Proteinuria
Wachtell et al. Ann Intern Med. 2003;139:901–906.
0.0
0.5
1.0
1.52.0
2.5
3.0
3.5
Composite
End Point
CV Mortal ity Al l-Cause
Mortality
Stroke MI
<0.25 mg/mmol
≥9.43 mg/mmol
A d j u s t e d H a z
a r d R a t i o
A d j u s t e d H a z
a r d R a t i o
Urine AlbuminUrine Albumin--toto--Creatinine Ratio*Creatinine Ratio*
*Comparison of lowest and highest decile of urine albumin*Comparison of lowest and highest decile of urine albumin--creatinine ratio.creatinine ratio.
Primary composite end point: cardiovascular death, stroke, MI.Primary composite end point: cardiovascular death, stroke, MI.
N = 7143
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Probability of Microalbuminuria or Proteinuria TestingWithin Past Year in Diabetic CKD (± comorbidity)
Source: USRDS Coordinating Center — Allan Collins (2005)
26
CKD Mostly Is …
Diabetes mellitus
T1DM x >16 y
T2DM x >10 y
Primary hypertension
Benign angiosclerosis
Nephrosclerosis
27
Risk Factors → CKD
NON-MODIFIABLE
1. Older age
2. Ethnicity
3. Male gender 4. Autoimmunity
5. Preeclampsia
6. Low birth weight
7. (+) FH of ESRD
MODIFIABLE
1. DM, CMS, Obesity
2. HTN
3. Proteinuria4. Recurrent UTI
5. Cigarette smoking
6. Nephrotoxic exposure
7. Urine outlet obstruction
8. Low: income, education
9. Poor healthcare access
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CKD ESRD Questionnaire“All in the Family”
Data from 25,883 HF pt
23% w/ close family members w/ ESRD Genetics implied (AA risk 2-fold greater)
Pt <55 y.o. with ESRD were 66% morelikely to have a (+) FH than those whodeveloped ESRD at >75.
Freedman B, VolkovaN, Satko S, et al. Population-based screening for family history of end-stage renal disease among incident dialysis patients. Am J Neph 2005; 25:529–535
29
Risk Factors → CKD
NON-MODIFIABLE
1. Older age
2. Ethnicity
3. Male gender
4. Autoimmunity
5. Preeclampsia
6. Low birth weight
7. (+) FH of ESRD
MODIFIABLE
1. DM, CMS, Obesity
2. HTN
3. Proteinuria
4. Recurrent UTI
5. Cigarette smoking
6. Nephrotoxic exposure
7. Urine outlet obstruction
8. Low: income, education
9. Poor healthcare access
30
GFR RATIONALE
CKD — “silent” and underrecognized
CKD — risk multiplier of CVD
CKD — co$tly ESRD program
Early Warning System requirement
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Estimating Kidney Function bySCr Underestimates GFR
Theory
x • y = k
Glomerular Filtration Rate
C C r
/ C i n
Glomerular Filtration Rate
C C r
/ C i n
Glomerular Filtration Rate
C C r
/ C i n
CKD: ♀ SCr >1.2 mg/dL or ♂ SCr >1.4 mg/dL
( ) )(2.1742.0186203.0154.1
AA f AgeS GFR Cr ××××= −−
32
Probability of Obtaining SCr
in CKD, DM and CHF
33
CKD DEFINED IN STAGES
GFR — best index of kidney function
Two estimations >3 mo apart
GFR determined from 4 variables Age & SCr
Ethnicity and gender
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CKD Prevalence in USNHANES III
5.95.3
7.6
0.4 0.3
Source: J Coresh. Am J Kidney Dis 2003;41(1):1–12
35
NKF CKD GFR Stages
%N
(1000s)
0.1300< 15 or Dialysis/Tx*Kidney Failure5
(585.5 / 6)
0.240015–29Severe ↓ GFR4
(585.4)
4.37,60030–59Moderate ↓ GFR3
(585.3)
3.05,30060–89Kidney Damage with
Mild ↓ GFR
2
(585.2)
3.35,900≥ 90Kidney Damage with
Normal or ↑ GFR
1
(585.1)
Prevalence1
GFR
(ml/min/1.73 m2)DescriptionStage
1After initiation of dialytic therapy or transplantation — ICD-9 Code 585 .62 More CKD patients die of CVD before reaching CKD Stages 4 and 5
36
ICD-9-CM Codes Usage for CKD
• ICD-9-CM used in just 1% of all pts
GFR Sensitivity Specificity
30-59 6 97
< 30 39 96
* GFR in ml/min/1.73 m2
Courtesy : LA Stevens
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CKD Patient Unawareness
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GFR Stratifies Risk of CV Events in CKD
AS Go, et al. NEJM. 2004N=~1,1 million
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Risk of Developing ESRDVersus Death Pre-ESRD
45.724.319.5Death prior to ESRD
19.91.31.1ESRD
Stage 4Stage 3Stage 2N=27,998
Keith et al. Arch Int Med 2004
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The Tipping PointTransition from CKD Stage 3 → 4
Source: NY Times (2000)
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ESRD (USRDS) Increases CV MortalityOver General Population (NCHS)
Source: M Sarnak, et al. AJKD, 1998.
0.01
100
10
1
0.1
Annual mortality (%)
25–34 45–54 65–74 8535–44 55–64 75–84
Male
Female
Black
White
Dialysis
General population
Age (years)
42
N o r m a l SCr High SCrP arameter
Mortality (per 1000 pt-yr)
13.0 35.8CVD
29.5 76.7Overall
Incident (per 1000 pt-yr)
31.8 54.0CVD
11.9 21.1Stroke
17.0 38.7CHF
CV Health Study(N = 5508; 7.3 yr)
Source: LF Fried, et al. J Am Coll Cardiol 2003;41:1364–1372.
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CKD Continuous Interactions withDM & CHF — Risk Multiplier
Source: USRDS Coordinating Center, ADR 2005 (Allan Collins)
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Success in CKD
STRATEGY
1. Screen for CKD
2. Kidney-centric Dx
3. CKD Stage by GFR
ACTION PLAN
1. ID Complications
2. General therapy
3. Specific therapy
4. E/M and Level
CKD Clinic Model
General:Biochemical ProfileUA Dipstick
Diabetes / HTN:UACR (UPC)Lipid profile
45
HFHS Retrospective Analysis of CKD Defined by SCr
• CKD Stage 1 & 2 pt progressed to Stages2 and 3, respectively, in just 3.1 years
• 35% of sample population (N =500)progressed to CKD Stage 5 by 09/05
• ~909 pts of total population (~2600)developed ESRD
• Much >17% projection of NKF
Source: S Frinak & J Yee.
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46MDRD GFR (ml/min/1.73 m2)
0
5
10
15
20
25
30
S a m p l e P o p u l a t i o n ( % )
0 15 30 45 60 75 90 105 120 135 150 165 180 195
5 4 3 2
CKD Stage 1: 5.9%
CKD Stage 2: 7.4%
CKD Stage 3: 32.2%
CKD Stage 4: 28.4%
CKD Stage 5: 26.1%
MDRD GFR at 1st Clinic Visit All Pts w/SCr >2.0 mg/dL in 1999
47
CKD ComplicationsEvolution and Acceleration
CKD Stage
1 2 3 4
Affected
pts
(%)
0
20
40
60
80
100
Hypertension
Secondary HPT
Anemia (Hgb < 12 g/dl)
Phosphorus > 4.5 mEq/L
Fail 1/4 mi walk
Hypoalbuminemia(Alb <3.5 g/dl)
DM, ARF: CKD complications may occur earlier
48
HFHS CKD Guidelines for PCPs
A. Form-fitted for lab coat pockets B. Downloadable pdf file
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50
51
CKD PlaybookMultidisciplinary Approach
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CKD Cardiovascular DomainHeart Failure w/ CKD (405.19)
*All patients with cardiologist-diagnosed HF and angiographically-proven CAD.N = 3914 for CCr ≥60 mL/min and N = 2513 for <60 mL/min.Source: J Ezekowitz, et al. JACC . 2004;44:1587.
P <0.001 P =0.004 P =0.002 P =0.04
P =0.03 P =0.02 P =0.006 P =0.03
Creatinine clearance ≥60 mL/min Creatinine clearance <60 mL/min
0
5
10
15
20
25
BB Statin ASA ACE BB Statin ASA ACE
O n e - Y e a r M o r t a l i t y * ( % )
User Nonuser
53
CKD PlaybookImmunization
TIV annualEGHP, 8% success rate in ESRDMedicare, 43% benchmark
PPV-23 before age 65 y.o.
54
Vaccinations in CKD
Vaccinate CKD Stage 4 pts most likely to progress to ESRD HBV titer at CKD Stage 5 is often low
May immunize HCV (+) pts
HEPATITIS B VACCINES FOR CKD: DOSES & SCHEDULES
Group Recombivax HB ®
Engerix B
Age /
CKD Stage
Dose
(mcg)
Vol
(mL)
Schedule Dose
(mcg)
Vol
(mL)
Schedule
>20 y.o.
Stages 1–4
40 1.0 3 doses at
0, 1 & 6 mo
40 2 × 1.0
1-site
4 doses at
0, 1, 2 and 6 mo>20 y.o.
Stage 5
40 1.0 3 doses at
0, 1 & 6 mo
40 2 × 1.0
1-site
4 doses at
0, 1, 2 and 6 mo
S Ibrahim, et al. J Nat Med Assn. 98(12):1953–1957, 2006
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55Source: J Yee & G Krol 2005. Chronic Kidney Disease (CKD): Clinical Practice Recommendations For Primary Care Physicians and Healthcare Providers — A Collaborative Approach (ed.4), p. 32. Johnson Printing Services, Novi.
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CKD Automation
CKD
Patient DB
E/M Software
Anemia management
Inpatient DB
ESRD
Vascular access
CRBSI
All labs
MCP documentation
Kidney Transplant DB Coming Online?
57
HFHS CKD CLINIC METRICS
BP Control
SHPT
Anemia mgmt
Vaccinations 50%
AVF rates
MD 70% v CNP 73%
CNP > MD
MD = CNP
CNP > MD (<5% diff)
25 → 40%
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BP Control Prevents CKDProgression
GFR , glomerular filtration rate; HTN, hypertension;MAP , mean arterial pressure. Adapted from Bakris GL et al. Am J Kidney Dis. 2000;36:646-661.
G F R
D e c l i n e
( m L / m i n / y )
0
-2
-4
-6
-8
-10
-12
-14
MAP (mm Hg)
95 98 101 107104 110 113 116 119
r=0.69; P <.05
UntreatedHTN
130/85 140/90
59
HFHS CKD CLINIC METRICS
BP Control
SHPT
Anemia mgmt
Vaccinations 50%
AVF rates
MD 70% v CNP 73%
CNP > MD
MD = CNP
CNP > MD (<5% diff)
25 → 40%
Primary Care Physicians’ Referral Patterns?
60
0.6
0.7
0.8
0.9
1.0
0 200 400 600 800 1000
Days after Dialysis Initiation
P r o b a b i l i t y
o f S u r
v i v a l
Survival Probability in Dialysis PatientsStandard v MultiDisciplinary Clinic Approach
Survival After Initiation of Chronic Dialysis Therapy
Standard Care
MDC
Log-rank P = 0.01
BM Curtis, et al. NDT. 2005;20(1):147–154
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Other Projects
Training other kidney-related health careproviders in systematic application of CKD careand management
Refining business processes C(omputerized)QI
Software development tools Managing = Measuring (fellows’ projects) Frequent data reviews with GHS
CKD Symposia / Lectures Partnering with healthcare providers and CKD-
related organizations
63
CKD Education for PCP
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Other Projects
Training other kidney-related health careproviders in systematic application of CKD care
and management Refining business processes C(omputerized)QI
Software development tools Managing = Measuring (fellows’ projects) Frequent data reviews with GHS
CKD Symposia / Lectures Partnering with healthcare providers and CKD-
related organizations
65
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CKD Overview Pay Me Now Or Pay Me Much More Later
The superior doctor prevents sickness; The mediocre doctor attends to impending sickness;
The inferior doctor treats actual sickness.
— Chinese Proverb —
… the ghosts of dead patients that haunt us do not ask why
we did not employ the latest fad of clinical investigation.
They ask us, why did you not test my urine?
— Sir Robert Grieve Hutchison (1871–1960) —
68
Optimal CKD Solution
1. Understand co$t$avings of early ID
1. Pay for prevention
2. Delaying E$RD issubstantial co$t ↓
2. Screen for CKD
• GFR automat ion
• Labs & UA
3. Educate healthcare
system about CKD
A. CKD Clinics
B. Collaborate w/ PCPs
C. Integrate
• Dialysis provider(s)
• Social work
• Kidney nutritionist
• Vascular accesssurgeons
• Transplant surgeons