A new report released by the RAND Corporation on chronic kidney disease suggests that treating such individuals more aggressively with practice guidelines and diagnostic tools now available could reduce the risks of kidney failure. But funding and a unified approach to best practices remains a major stumbling block.

The report, entitled "Chronic Kidney Disease--A Quiet Revolution in Nephrology by RAND researcher Richard A. Rettig, and nephrologists Roberto B. Vargas, Keith C. Norris, and Allen R. Nissenson, includes a review of how CKD care was handled by six physician practices around the country. The report is sponsored by the National Institutes of Health's National Center for Research Resources, which funded the Comprehensive Center for Health Disparities at Charles Drew University.

Developing a continuum of care
The report notes that public policy over the last four decades has defined kidney disease primarily by its endpoint: end-stage renal disease. While greater emphasis has been placed recently on identifying and treating the early stages of chronic kidney disease, for medicine, CKD represents a challenge in moving from a chronic disease treatment model to a model that balances the relationship between prevention and care, the authors write. For policy, the key issues involve the reimbursement of care, i.e., who will pay for the range of care associated with the expanded understanding of CKD.
The report notes that, with recently established guidelines and classifications for CKD, the diagnosis of kidney disease is attainable. But the potential for slowing the progression of the disease with treatment has yet to receive adequate attention within nephrology and by policymakers, and some significant barriers remain to
improved care for CKD patients.

Some key factors that prevent early treatment:

• Treatment of ESRD is paid for through Medicare, but early treatment of CKD is not.
• There is a lack of coordination between primary care physicians (PCPs) and nephrologists.
• The public is not well informed regarding CKD.
• There is a lack of consensus among health care providers concerning the importance of CKD.
• There is a need for data concerning the effectiveness of different tests and therapies for CKD.
  

In developing the report, the authors undertook a series of 15 telephone interviews, which were followed by site visits to six CKD clinics or practices.

"Our telephone interviews raised several key themes concerning CKD practices today, many of which were later echoed in the case studies, the authors wrote. "Most practices we interviewed favored early intervention, although several expressed ambivalence, and a few thought the payoff was greater when treatments were started in later stages of CKD," the authors wrote. The practices identified a number of problems and challenges in treating CKD patients, including limited reimbursement, lack of patient awareness of CKD, and difficulty in identifying CKD patients and in creating patient histories from multiple sources.

Recommendations
The authors offered the following recommendations to improve CKD care:

• Appropriate reimbursement needs to be available to screen at-risk populations and to enable ongoing care by physicians as CKD is diagnosed and progresses. 
• Patient referral, the other critical resource, requires negotiations between nephrologists and other providers and specialists at the local clinic or practice level, as well as at the level of the pertinent professional societies. 
• Screening patients for CKD by eGFR should be made obligatory by Medicare and state Medicaid agencies, and private insurers should be strongly encouraged to pay for such screening. 
• Education is critical. Both patients and providers need to be educated about the prevalence of CKD, who is at risk, who should be treated, and which treatments are effective in slowing the progression of the disease, as well as treating its complications and those associated with comorbid conditions that are present. 
• CKD clinical practice needs to integrate the efforts of PCPs, cardiologists, endocrinologists, nephrologists, and nonphysician care providers to optimize clinical outcomes.Coordinated care management, relying on available best medical evidence, needs to drive clinical decisions and practice. 
• Available clinical practice guidelines, such as the Kidney Disease Outcomes Quality Initiative  guidelines published by the National Kidney Foundation and the Renal Physicians Association  guidelines, need to be integrated into actual clinical practice. 
• Consistent with current health reform efforts, robust HIT is essential to track and evaluate care across various delivery sites.
• Nephrologists and other providers need to be held accountable for the outcomes of their patients. 
• Substantial investments in translational and health services research are needed to better understand how to prevent CKD, treat it when it occurs, and carry out these activities efficiently and effectively.
  

"The crisis of nephrology lies in an unresolved tension between the specialtys increasing ability to do the right thing clinically (by providing effective preventive care) and the persistent realities of major barriers to doing so, including inadequate reimbursement, weak working relations between nephrology and other specialties, organizational impediments, ineffective clinical procedures, and a lack of HIT systems," the authors wrote. "To the extent that our observations identify models of improved access to CKD care for all individuals as well as efforts targeted at minority populations, this work may help eliminate disparities in kidney disease outcomes. Action on CKD policy will equip clinicians with the basic tools to respond to such factors.