mproving Access to Nephrology Treatment and Care among Patients at Greatest Risk for Kidney Failure

Emory University, Atlanta GA

Investigators

Abstract

Improving Access to Nephrology Treatment and Care among Patients at Greatest Risk for Kidney Failure Nearly 15% of U.S. adults have chronic kidney disease (CKD),1 yet because symptoms are often “silent,”2 only an estimated 12-19% are aware of their disease. A lack of a diagnosis results in substantial delays in accessing necessary care, such as referral to a nephrologist, that can optimize outcomes. This is particularly concerning for patients with advanced CKD who are nearing the transition to end-stage kidney disease (ESKD) and will likely require imminent kidney replacement therapy (KRT). For an optimal ESKD transition, patients should have received pre-ESKD nephrology care, a permanent vascular dialysis access ready for use, and have education on available KRTs options.3,4 Ideally, they should be able to start KRT in the outpatient setting and/or receive a preemptive kidney transplant (i.e., kidney transplant prior to starting dialysis). However, in 2022, 74% of patients started KRT with only a central venous catheter,1 at least 46-75% started KRT in the inpatient setting, and nearly one third started KRT with no/unknown pre-ESKD nephrology care.5,6 The Collaborative Chronic Care Model offers a well-established, multi-level framework for organizing health systems in order to maximize outcomes among patients with chronic diseases such as CKD; thus, we seek to apply it to the problem of suboptimal transition to KRT. We propose multi-level, multi-component interventions under a new innovative framework to motivate systemic change to impact CKD care in primary care and acute care access points. In this manner, we propose to redesign structures within Emory Healthcare to support the transition to KRT in a way that ensures access to timely, guideline-compliant nephrology treatment and care. Our long-term goal is to improve access to nephrology care among patients within Emory Healthcare who are at greatest risk for kidney failure by developing a model of care that can be replicated and sustained within health systems across the country. Our central hypothesis is that with substantial input from patients themselves, comprehensive systems change will improve access to all steps of care along the CKD continuum among patients who need it most. Thus, we seek to carry out the following three specific aims: Implement multi-level, multi-component interventions across primary care and acute care access points and nephrology care. Using an experimental research design, determine the effectiveness of a kidney health coaching intervention on delaying a) the transition to kidney replacement therapy and central venous catheter use and b) death. Evaluate implementation and support dissemination of the multi-level, multi-component interventions using the RE-AIM framework to assess Reach, Effectiveness, Adoption, Implementation, and Maintenance/Sustainability.