Dr. Nicholas
Welcome everyone to the last episode of our podcast series on “Diabetes and Kidneys: Unraveling T2D’s Silent Threat.”

Dr. Nicholas
We're your hosts, Dr. Susanne Nicholas and Dr. Radica Alicic.

Dr. Alicic
Hello and welcome.

Dr. Nicholas
In our previous episodes, we discussed a number of topics that included a description of chronic kidney disease associated with type 2 diabetes, the screening and diagnosis of CKD associated with type 2 diabetes, disease progression, complications, and comorbidities and their impact, as well as early intervention strategies, and patient empowerment and education.

Dr. Alicic
Today, we'll talk about the healthcare system's role in early intervention for CKD associated with type 2 diabetes. We'll also discuss policy initiatives and guidelines and explore the challenges and potential solutions for improving access to early treatment in CKD associated with type 2 diabetes.

Dr. Nicholas
You know, it's been said that the healthcare system in the United States can be considered one of the barriers that prevents patients with chronic kidney disease associated with type 2 diabetes from actually getting the care that they need.¹ A shortage of primary care professionals, limited access to multidisciplinary teams, and a lack of health system preparedness can all impede the implementation of care for chronic kidney disease and also affect patients' education about their CKD, particularly in earlier stages.^1,2 Joining us today is Dr. Nihar Desai. He's a cardiologist and executive director of bundle payments and clinical service line operations at the Yale New Haven Health System. Dr. Desai will help to facilitate our discussion on policy initiatives and guidelines and help us explore the challenges and potential solutions for improving access to early treatment in CKD associated with type 2 diabetes. Welcome, Dr. Desai.

Dr. Desai
Thanks so much, Dr. Nicholas. Delighted to be with you.

Dr. Nicholas
Thank you. Let me ask the first question as we get started to talk about the role of the healthcare system when it comes to early intervention for CKD associated with type 2 diabetes. I want to pose this first question to Dr. Alicic. So, Dr. Alicic, as a primary care physician, what do you think about the role of the healthcare system on this topic?

Dr. Alicic
Primary care healthcare professionals play a crucial role in the care of the majority of the patients with chronic kidney disease, and majority of these patients are managed in the primary care setting.^3,4 Therefore, success of any CKD screening and treatment efforts will require primary care health care providers to be engaged and educated about the CKD risk and stratification, particularly the importance of albuminuria.² That is why I especially appreciate the ADA and KDIGO efforts to focus on multidisciplinary teams that will include primary health care providers.⁵ In my opinion, this initiative will ultimately lead to improved crosstalk between specialties and less fragmented care of these patients.

Dr. Nicholas
Dr Desai, do you feel as a specialist that it's hard to communicate with other health care professionals, who are also responsible for the care of your patient with CKD associated with type 2 diabetes?

Dr. Desai
Yeah, Dr. Nicholas, it's a great question. As your question alludes to, many providers are caring for these patients that have CKD and type 2 diabetes.^1,6 Obviously, there's the primary care physician, the endocrinologist, the nephrologist, oftentimes a cardiovascular medicine specialist like myself, should they have the need for that type of clinical care.^1,6 I think there's an inherent challenge in how we communicate as a clinical care team, surrounding the patient, and providing them good, comprehensive, longitudinal care.¹ And I think oftentimes, we all think that the other person is going to be the point person for something. And so maybe, though all of could be involved in screening and risk stratification and implementation of therapies,⁵ we often leave that thinking that maybe one of our colleagues will do it. I think one of the questions that we have to confront is, given what our patients want and need, which is coordinated, multidisciplinary, team-based care,^6,7 how can we work to better communicate with each other? How do we make things easier for all of us? I think primary care physicians, especially, are overburdened.^1,3 They have very little time, really feeling the pressures of increasing throughput, increasing numbers of visits, shortening times, but yet still having to do documentation and billing and all of the follow-up that's inherent to providing good comprehensive primary care.^3,8,9

Dr. Desai
One of the things that we've been thinking about is, how do we bring existing guidelines? How do we bring clinical pathways? How do we bring education really to the whole care team, and especially our primary care provider colleagues? I think one of the things that we have to think about for that is how to leverage the electronic health record to actually facilitate high-quality, high-value care. That, I think, remains an important opportunity for us as we think about true multidisciplinary, coordinated, patient-centered care, especially for our patients with CKD associated with type 2 diabetes.^8,10

Dr. Nicholas
Well, those are such excellent points. In fact, it makes me think about something that follows very closely on to inviting our primary care physicians and providing guidance. I'm thinking about the economic impact of late identification of CKD in patients with type 2 diabetes. As you have mentioned about use of the electronic health records, that can help us to identify individuals with CKD and type 2 diabetes at any stage of CKD.^8,10 But there's this other element that is so important, and I know this is an area of expertise for you. So please, tell me, what are your thoughts on the economic impact of late identification of CKD in our patients with type 2 diabetes?

Dr. Desai
Yeah, Dr. Nicholas, that's such an important point. I think we all know and understand, and it's frankly hard to overstate the clinical impact of late identification of CKD in patients that have diabetes. There is, again, the adjunctive component to that story, which is really the economic impact. Here, the numbers are just as staggering and just as sobering. I think a couple of important points that I think the audience would find interesting. First, when you look at broad administrative claims data and you look adults with diabetes, what we know is that patients that have CKD, concomitant with diabetes, have substantially higher medical care expenditures when compared to patients with diabetes who do not have chronic kidney disease.¹¹ That's one important point that the concomitant association of diabetes with CKD substantially increases healthcare spending and healthcare utilization.^11,12 The other, I think, important part of that story is, and this was studied in a recent meta-analysis and a systematic review of almost 30 studies that looked at the association of eGFR and albuminuria with risks of adverse outcomes, including cardiovascular morbidity, mortality.¹³ What it found, again, is not going to be surprising to our audience, that increased rates of albuminuria were associated with increased risks of adverse events.¹³

Dr. Desai
Even within the same CKD stage, those patients that have higher rates of albuminuria, so a urine-albumin-creatinine ratio greater than 300 mg/g, had a 4-8 times greater cost for care when compared to those patients with a UACR of less than 30 mg[/g].¹³ I think, as you and others have rightfully discussed in this entire series, that there has to be a sense of urgency in identifying and managing the CKD and type 2D.² There's also a very compelling economic impact and economic narrative for why early identification, early treatment, and use of highly effective therapies like the ones that you have talked about is incredibly important for these patients.^2,14

Dr. Nicholas
So true. That also brings us to discuss some of the regulations and the initiatives that are out there. I'd like to bring my colleague, Dr. Alicic, into the discussion again and to ask Dr. Alicic, are you aware of the National Kidney Foundation's addition to the HEDIS measures?

Dr. Alicic
Thank you, Dr. Nicholas. I am aware that the National Kidney Foundation developed the Kidney Health Evaluation for Patients with Diabetes, a part of HEDIS measures, to ensure that the electronic clinical quality measures for eGFR and UACR testing, and disseminations was implemented in commercial health insurance plans in the US, and this is supported by the National Committee for Quality Assurance.^15,16 This measure counts the percentage of members 18 to 85 years of age with diabetes who received a kidney health evaluation defined by an eGFR and UACR measurement during [an] annual calendar year.¹⁶ For example, in 2022, the national averages for the measure ranged from 35 to 46%, depending on the type of insurance.¹⁷

Dr. Nicholas
Yes, and even the American Society of Nephrology and their quality committee did a review of existing kidney care-related metrics in 2020, and they determined that fewer than half of all of the metrics at the time were considered to have high validity.¹⁸ In addition, there are only two metrics that were found to address specifically slowing chronic kidney disease progression.¹⁸ There's a metric by the National Quality Forum, measure 1622, and this measure addresses whether there's appropriate therapy being delivered  or provided to patients with proteinuria.¹⁸ There’s another measure by the Renal Physicians Association, measure 122, which takes a look at whether patients have documented plan of care.¹⁸ The committee from the American Society of Nephrology also believe that many of the measures for kidney care should not be attributed to nephrologists, such as, for example, chronic kidney disease prevention and vascular access related measures.¹⁸ Really interesting. With that, I'd like for us to now explore any potential initiatives that we all feel may be needed and that may benefit patients with CKD associated with type 2 diabetes. To get the conversation started, I want to just mention that there are certain themes that always come to my mind that I think can be persistent across all stages of CKD that need to be addressed.^7,19,20  

Dr. Nicholas
One is education, one is self-empowerment, and I think education leads to self-empowerment for the patient, and the other is shared decision making between the provider as well as the patient.^7,19,20 Dr. Desai, any thoughts on some initiatives that might benefit our patients?

Dr. Desai
Yeah, Dr. Nicholas, I think that's such an important point, and I think I couldn't reinforce more strongly where you started us off with that notion of patient activation, education, really being part and advocating for care. I think in parallel to that, we then need a healthcare system that's really oriented around prevention, that's really thinking about early identification of at-risk populations, that's thinking deep about implementation of evidence-based therapies, things that are relevant for patients early on in maybe stage 1, stage 2, all the way to stage 3 or 4, or maybe even more advanced kidney disease with their associated diabetes.^1,2 I think we're in this moment now where we have highly effective therapies for these patients that have CKD associated with type 2D that can really mitigate disease progression, that can mitigate adverse cardiovascular outcomes for these patients.^1,2 I think the question before us is, what is going to be required for us to translate that evidence, to bring those highly effective therapies to the patients and communities and populations who will benefit from them. I think, to your point, that certainly starts with many of the things that you have talked about. I think there's a very important role in terms of the ecosystem of care around quality measurement and performance measures that really align with the incentives of the patient and providers.^1,2,15,18

Dr. Desai
Then I think, similarly, we need a system of care and thinking about how to create a high functioning healthcare delivery system that really can get the therapies that we know are highly effective, again, to the patients and communities and populations who need them.¹

Dr. Nicholas
I couldn't agree with you more, and you've touched on such important topics. As we've discussed a little bit about the healthcare system, let me ask you the next question that's on my mind. What do you think the healthcare system should focus on when it comes to early identification and treatment of CKD in our patients with type 2 diabetes?

Dr. Desai
Yeah, Dr. Nicholas, that's a really great question. I think, again, as you and others have been talking about and also writing about, the stakes here are awfully high. We know what happens to patients that have CKD associated with type 2D. We know what happens if they don't get the highly effective therapies and interventions that they can and should get based on the guidelines and based on very, very high quality evidence.^5,13,14 I think one of the things that we have to confront is that the incentives that health systems face are not necessarily always aligned with early identification and prevention and implementation of evidence-based therapies that can actually mitigate disease progression when we think about our patients with CKD associated with type 2D.^1,2 For example, our financing system for healthcare is really predicated on a fee-for-service system, meaning that the more volume of procedures that we do, the more volume of care we provide, the more revenue the health system receives, and the more payment a provider group or a hospital system will receive.^1,2,21 Instead, preventing CKD, or preventing diabetes, or certainly preventing disease progression amongst those patients that have CKD associated with type 2 diabetes, one would think is an absolute priority for patients.

Dr. Desai
It's an absolute priority for providers.^2,5 That's what all of us want to do.^2,5 And yet the payment system, the financing model for health care, really doesn't reward that in the same way that it rewards doing costly procedures and doing other kinds of care management.^1,2 One of the things that I think health systems could do, to be appropriately incentivized, is to really think about and participate in alternative payment models or pay for performance programs, really thinking about population-based models of care where they are incentivized for prevention of disease, prevention of complications, avoidance of complex cardiovascular comorbidities, morbidity, and mortality. Again, this is a prime example. These patients that have CKD associated with type 2D, where we know there are highly effective, high-value therapies, including a number of pharmacotherapies that can reduce risk for patients, that can reduce the progression of kidney disease, that can prevent cardiovascular complications from happening.^1,2 I think the other important feature of a system that were appropriately incentivized prevention and maintenance of care or improvement of care, if you will, is that the cost of a therapy becomes a very small consideration when you look at overall health care utilization. We talk a lot about the cost of therapies and that we wish that costs and access for these therapies were improved.¹

Dr. Desai
And so if we were to step back and have a more population health-oriented model for health care financing, then I think that would actually align much, much better with the interests of our patients that have CKD and type 2D, and certainly what all of us as providers want to do, which is to partner with our patients, to engage with them, to advocate for them, to provide them highly effective therapies to both identify at-risk populations, and once they are found, to then implement the highly effective therapies that you and others have talked so much about.^2,5

Dr. Nicholas
Thank you so much for that, Dr. Desai. You raise really great points when you talk about alternative approaches, approaches that would result in decreased cost for care for our kidney patients, as well as decreasing adverse clinical outcomes by instituting the appropriate therapy. I think one of the good things that we have that we can look at, and I would like to bring my colleague, Dr. Alicic, to talk to us about the example, I would say the successful example, of the Indian Health Service and what they've done to reduce the incidence of kidney failure among American Indians and Alaska Native peoples.²² Dr. Alicic, tell us more about that.

Dr. Alicic
Thank you, Dr. Nicholas. I actually really enjoy sharing story of the Indian Health Services Project. So, between 1996 and 2013, they implemented program that was able to reduce incidence of kidney failure, end-stage kidney disease, in Native Americans and Alaska Native people by 54%.²² And they were able to do that while having per capita health expenditure equaling about only 40 % of that spent in the general US civilian population.²² So, we all understand the success, the measure of this success with keeping in mind that Native Americans and Alaska Native people have very high, disproportionately high incidence of kidney disease.²² So what did they do? So what they did were just implementing medical intervention utilized by everyday practitioners.²² They were focusing on glucose control, blood pressure control, and they used all the appropriate medical therapies.²² But they did implement a systemic population-based approach.²² They made multidisciplinary teams that included primary health care providers, but also dietitians, pharmacists, case managers, and laboratory professionals.²² They did not focus only on diabetes standards of care, but they broadened them to cover screening, identification, and treatment of complications of chronic kidney disease.²² They also provided appropriate nutritional counseling and patient education for chronic kidney disease.²²

Dr. Alicic
They also initiated preparation for kidney replacement in the primary care setting.²² Finally, what they added the case management of chronic kidney disease that was promoted within diabetes program.²² They did that through organizing 3-days long CKD case management workshops that were developed and made available to any health care provider.²² Furthermore, clinical guidelines, procedures of patient education, and patient education materials, as well as a treatment guidance for treatment of anemia, and other complications [of] chronic kidney disease, were available online, and that facilitated the implementation of care.²² I think we have a great lesson to learn from this example, primarily that we can address the complications of diabetes and chronic kidney disease in diabetes through population management and improvement of care.²²

Dr. Nicholas
That's really excellent. Just imagine if our health system could actually broaden that type of approach to other populations where the incidence of chronic kidney disease and type 2 diabetes is really high, such as African-Americans, for example.²³ I think we can only dream and hope that something like this could happen in the future. This brings us to the end of our final podcast. I'd like to invite Dr. Desai if he has any final words that he'd like to say to us or any comments regarding the health system and policies.

Dr. Desai
Well, thank you very much, Dr. Nicholas, Dr. Alicic. This was a terrific discussion, and I think you have really raised awareness about very important issues from diagnosis, prevention, treatment, and obviously, even a broader discussion like we had today around the health system, other factors, the ecosystem of care and what's happening, and maybe some of the important changes that we have to bring to bear for that. I guess if I was going to leave you with anything, I might say that for us to be successful, to really have a better delivery of care for patients with CKD and type 2D, it's exactly this example that Dr. Alicic just went through with us.²² It's going to require a reimagination of care.² It's thinking deep about who the care team is, what kind of care they're delivering, how they're partnering with patients in their own empowerment, in their own medical care and choices, and then how the incentives are really aligned for us to be able to deliver high-quality, high-value care, which is what we all want to do as clinicians and practitioners, and obviously what our patients and communities that we serve are desperately looking for. I just want to thank you again for the opportunity to be part of this and I really enjoyed it.

So, thank you again very much.

Dr. Nicholas
Wonderful. And thank you also. And with that, I'd like to thank both of my colleagues, Dr. Alicic and Dr. Desai, for such an amazing, comprehensive, and robust discussion, and for your perspectives on the healthcare system and the policies related to the care of patients with diabetes and chronic kidney disease. I do hope that our audience has had the opportunity to listen to all of the five prior podcast episodes and hope that this whole series was very educational and informative for them. Thank you.

Dr. Alicic
Thank you.

End out take
Audio tone.

Dr. Desai
Thank you guys again for the opportunity to be part of this. It's a really important discussion. Dr. Nicholas and Dr. Alicic, thanks again for.

Dr. Alicic
You know what, Dr. Desai? I really thank you for this discussion because it is so illuminating, enlightening, and pervasive. We talk about all these things we need to do it, but we understand from your perspective, there's a really pervasive incentive.

Dr. Desai
Yeah, I'm telling you. People are doing noble work. People are working really hard to take care of people under heroic kind of circumstances. If we could make the system a little bit better to make that incredible work a little bit easier, then I think that's the minimum that we owe people that are doing this work and really trying to take care of people. I'm still hopeful that we can continue to advocate for that and to do that and to raise awareness about the issues around CKD and type 2D and therapies and identification and risk stratification, but also on the broader policy side, on the ecosystem side of, hey, what else has to be done? And can the professional societies be involved in this? Can legislators and policymakers be involved in it?

Dr. Alicic
I think legislators and policymakers are needed. Native American, if they-

Dr. Desai
That's right. I mean, look at that. Look at that example!

Dr. Nicholas
I love the layering of all the information. I have to say that this is the best way to end this for, all the episodes.