HJNO Jul/Aug 2024

CHANGING THE CARE: CHRONIC KIDNEY DISEASE 34 JUL / AUG 2024 I  HEALTHCARE JOURNAL OF NEW ORLEANS   patients, but it is also an essential response to the explosion in medical knowledge that hap- pens every year. The entire volume of medical knowledge is doubling approximately every 73 days, and new medical articles are appear- ing at a rate of at least one every 26 seconds. If a physician were to read every medical jour- nal published, they would need to read 5000 articles per day. And since we have already referenced that it would take a primary care physician caring for a panel of 2500 patients an average of 26.7 hours per day to deliver all the evidence-based recommended care for that panel of patients, the plight of primary care providers and the reasons for their high rates of burnout becomes depressingly apparent. Indeed, in the current state of CKD manage- ment, the norm for many primary care pro- viders is to refer to nephrology while a pa- tient is still in stage CKD 3. The problem with that approach is that there are not enough nephrologists to handle the current burden of advanced CKD, let alone the earlier stages of CKD like CKD 3. The response among ne- phrologists is that they then hire advanced practice providers and teach them how to manage early-stage CKD. The good news is that these early stages of CKD are fairly al- gorithmic in nature, and any condition that can be managed via algorithm can be digi- tized and readily scaled. As mentioned in the prior articles on hypertension, diabetes, and hyperlipidemia, all three of those conditions can be managed by a sequential care pro- cess that specifies a series of steps using an if/then approach. CKD is not much different as evidenced by the number of algorithms depict- ed in the recently published 2024 CKD guide- lines. Even the management of anemia of CKD and CKD-mineral bone disorder (CKD-MBD) lend themselves to a sequence of prespecified steps capable of being delivered via digitally powered pathways. Digital solutions are a large part of the answer to the physician workforce shortage as less skilled and less expensive re- sources can be empowered to deliver better care than what is possible if the expectation of every PCP is to simply stay up-to-date with the latest evidence-based guidelines. The combi- nation of the right types of talent, teams, and technology coalesce to make the complex not only simple but reliably executable and repeatable to drive improved performance. While anemia of CKD does involve reduced production of a hormone known as erythro- poietin by the kidneys, we have learned that erythropoietin replacement is not necessary nearly as often as we used to think. Indeed, re- placing erythropoietin when hemoglobin levels are > 10 mg/dL can increase the risk of stroke. But that practice used to be commonplace, in part because reimbursement for erythro- poietin was so generous. Currently, managing anemia of CKD simply requires a primary care provider to understand that abnormalities in hepcidin interfere with oral iron absorption in these patients and results in iron deficiency that exacerbates their anemia. Administering intravenous infusions of iron is sometimes nec- essary and is simple and easy to do (although the complexity of navigating the EMR to order it is another matter entirely). Erythropoietin re- placement is still sometimes needed, but only after iron stores have been adequately replet- ed and only when hemoglobin levels are < 10. CKD-MBD likewise simply requires an under- standing that when phosphorus levels rise to > 4.5 in early stages of CKD the patient requires a dietitian to provide guidance on a low phos- phorus diet. If phosphorus levels get up into the range > 5.5, then phosphorus binders be- come necessary. Without getting into some of the nuances of the different types of phospho- rus binders, the important thing to understand is that calcium-containing binders are associ- ated with higher rates of mortality (presumably due to enhanced calcification of CVD plaques) and should only be used when serum calcium levels are low. Otherwise, non-calcium-con- taining phosphorus binders should be utilized. And vitamin D levels and parathyroid hormone levels should be checked at regular intervals according to the KDIGO heat map illustrated in the CKD guidelines as well as our previ- ous article on CKM syndrome. Then, all that is necessary is ensuring that vitamin D stores are replete and knowing when supplement- ing with calcitriol or cinacalcet becomes nec- essary. The point is not to provide a detailed understanding of the management of anemia of CKD and CKD-MBD, but rather to point out that their management essentially consists of a series of if/then sequential steps that lend themselves to algorithm and digitization. Investment in these digital solutions makes perfect business sense whenever a health system begins to take on larger proportions of actuarial financial risk for the total cost of care. And even though the commercial pay- ers take on financial risk for total cost of care for their fully insured book of business, they continue to lag in payment innovation and reimbursement for these digital solutions for reasons that are complex, but at least partially discussed in this and previous ar- ticles. Improving health outcomes and mak- ing healthcare more accessible and afford- able is not really that hard, but navigating the complexity of payment across multiple payers is exceedingly complex and contrib- utes to the many woes of healthcare as we currently know them. However, perseverance despite economically deleterious headwinds is vitally important, and at least for those sys- tems that continue to strive to deliver im- proved health, it is the only course of action because it is simply the right thing to do. n REFERENCE 1 Teitelbaum, I.; Finkelstein, F. “Why are we Not Getting More Patients onto Peritoneal Dialysis? Observations From the United States with Global Implications.” Kidney International Reports 8, is- sue 10 (July 25, 2023): 1917-1923. doi: 10.1016/j. ekir.2023.07.012 2 D’Amario, D.; Rodolico, D.; Delviniati, A.; et al. “Eligibility for the 4 Pharmacological Pillars in Heart Failure With Reduced Ejection Fraction at Discharge.” Journal of the American Heart Asso- ciation 12, issue 13 (July 4, 2023): e029071. doi: 10.1161/JAHA.122.029071 “Improving health outcomes and making healthcare more accessible and affordable is not really that hard, but navigating the complexity of payment across multiple payers is exceedingly complex and contributes to the many woes of healthcare as we currently know them.”