CKD_Payor

7/31/2019 CKD_Payor

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CKD Overview

Jerry Yee, MD

Paying Too Little or Too Little Prevention

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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

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“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 …

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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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CKD: A Mortal Disorder

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$tate of E$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).

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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%

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ESRD Expenditures from Paid Claims

Source: USRDS Coordinating Center, ADR 2005 (Allan Collins)

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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


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CKD CareEGHP Wor$e Than Medicare

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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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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

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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)

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Early Referral Difference

Infection

Late ReferralEarly Referral

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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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CKD Is …

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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

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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)

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CKD Mostly Is …

Diabetes mellitus

T1DM x >16 y

T2DM x >10 y

Primary hypertension

Benign angiosclerosis

Nephrosclerosis

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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

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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

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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


C C r

/ C i n


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 ××××= −−

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Probability of Obtaining SCr

in CKD, DM and CHF

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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

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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

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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)

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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


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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

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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

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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

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HFHS CKD Guidelines for PCPs

A. Form-fitted for lab coat pockets B. Downloadable pdf file

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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

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CKD PlaybookImmunization

TIV annualEGHP, 8% success rate in ESRDMedicare, 43% benchmark

PPV-23 before age 65 y.o.

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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?

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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

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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?

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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

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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

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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) —

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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

CKD_Payor

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