A Population-Based Analysis of Quality Indicators in CKD

A CKD Clinical Decision Support System: A Cluster Randomized Clinical Trial in Primary Care Clinics

Rationale & Objective

The study aimed to develop, implement, and evaluate a clinical decision support (CDS) system for chronic kidney disease (CKD) in a primary care setting, with the goal of improving CKD care in adults.

Study Design

This was a cluster randomized trial.

Setting & Participants

A total of 32 Midwestern primary care clinics were randomly assigned to either receive usual care or CKD-CDS intervention. Between April 2019 and March 2020, we enrolled 6,420 patients aged 18-75 years with laboratory-defined glomerular filtration rate categories of CKD Stage G3 and G4, and 1 or more of 6 CKD care gaps: absence of a CKD diagnosis, suboptimal blood pressure or glycated hemoglobin levels, indication for angiotensin-converting enzyme inhibitor or angiotensin receptor blocker but not prescribed, a nonsteroidal anti-inflammatory agent on the active medication list, or indication for a nephrology referral.

Intervention

The CKD-CDS provided personalized suggestions for CKD care improvement opportunities directed to both patients and clinicians at primary care encounters.

Outcomes

We assessed the proportion of patients meeting each of 6 CKD-CDS quality metrics representing care gap resolution after 18 months.

Results

The adjusted proportions of patients meeting quality metrics in CKD-CDS versus usual care were as follows: CKD diagnosis documented (26.6% vs 21.8%; risk ratio [RR], 1.17; 95% CI, 0.91-1.51); angiotensin-converting enzyme inhibitor or angiotensin receptor blocker prescribed (15.9% vs 16.1%; RR, 0.95; 95% CI, 0.76-1.18); blood pressure control (20.4% vs 20.2%; RR, 0.98; 95% CI, 0.84-1.15); glycated hemoglobin level control (21.4% vs 22.1%; RR, 1.00; 95% CI, 0.80-1.24); nonsteroidal anti-inflammatory agent not on the active medication list (51.5% vs 50.4%; RR, 1.03; 95% CI, 0.90-1.17); and referral or visit to a nephrologist (38.7% vs 36.1%; RR, 1.02; 95% CI, 0.79-1.32).

Limitations

We encountered an overall reduction in expected primary care encounters and obstacles to point-of-care CKD-CDS utilization because of the coronavirus disease 2019 pandemic.

Conclusions

The CKD-CDS intervention did not lead to a significant improvement in CKD quality metrics. The challenges to CDS use during the coronavirus disease 2019 pandemic likely influenced these results.

Funding

National Institute of Diabetes and Digestive and Kidney Diseases (R18DK118463).

Trial Registration

clinicaltrials.gov Identifier: NCT03890588.

Optimizing Care Delivery in Patients with Chronic Kidney Disease in the United States: Proceedings of a Multidisciplinary Roundtable Discussion and Literature Review

BACKGROUND

Approximately 37 million individuals in the United States (US) have chronic kidney disease (CKD). Patients with CKD have a substantial morbidity and mortality, which contributes to a huge economic burden to the healthcare system. A limited number of clinical pathways or defined workflows exist for CKD care delivery in the US, primarily due to a lower prioritization of CKD care within health systems compared with other areas (e.g., cardiovascular disease [CVD], cancer screening). CKD is a public health crisis and by the year 2040, CKD will become the fifth leading cause of years of life lost. It is therefore critical to address these challenges to improve outcomes in patients with CKD.

METHODS

The CKD Leaders Network conducted a virtual, 3 h, multidisciplinary roundtable discussion with eight subject-matter experts to better understand key factors impacting CKD care delivery and barriers across the US. A premeeting survey identified topics for discussion covering the screening, diagnosis, risk stratification, and management of CKD across the care continuum. Findings from this roundtable are summarized and presented herein.

RESULTS

Universal challenges exist across health systems, including a lack of awareness amongst providers and patients, constrained care team bandwidth, inadequate financial incentives for early CKD identification, non-standardized diagnostic classification and triage processes, and non-centralized patient information. Proposed solutions include highlighting immediate and long-term financial implications linked with failure to identify and address at-risk individuals, identifying and managing early-stage CKD, enhancing efforts to support guideline-based education for providers and patients, and capitalizing on next-generation solutions.

CONCLUSIONS

Payers and other industry stakeholders have opportunities to contribute to optimal CKD care delivery. Beyond addressing the inadequacies that currently exist, actionable tactics can be implemented into clinical practice to improve clinical outcomes in patients at risk for or diagnosed with CKD in the US.

An Overview of Chronic Kidney Disease Pathophysiology: The Impact of Gut Dysbiosis and Oral Disease

Chronic kidney disease (CKD) is a severe condition and a significant public health issue worldwide, carrying the burden of an increased risk of cardiovascular events and mortality. The traditional factors that promote the onset and progression of CKD are cardiometabolic risk factors like hypertension and diabetes, but non-traditional contributors are escalating. Moreover, gut dysbiosis, inflammation, and an impaired immune response are emerging as crucial mechanisms in the disease pathology. The gut microbiome and kidney disease exert a reciprocal influence commonly referred to as "the gut-kidney axis" through the induction of metabolic, immunological, and endocrine alterations. Periodontal diseases are strictly involved in the gut-kidney axis for their impact on the gut microbiota composition and for the metabolic and immunological alterations occurring in and reciprocally affecting both conditions. This review aims to provide an overview of the dynamic biological interconnections between oral health status, gut, and renal pathophysiology, spotlighting the dynamic oral-gut-kidney axis and raising whether periodontal diseases and gut microbiota can be disease modifiers in CKD. By doing so, we try to offer new insights into therapeutic strategies that may enhance the clinical trajectory of CKD patients, ultimately advancing our quest for improved patient outcomes and well-being.

Poor adherence to clinical practice guidelines: A call to action for increased albuminuria testing in patients with type 2 diabetes

We describe the substantial shortfall in adherence to guideline-recommended albumin-to-creatinine ratio (uACR) testing for people in the United States with type 2 diabetes. Poor compliance with current guidelines leads to delays in diagnosis-and treatment- of chronic kidney disease, which adversely affects clinical outcomes and contributes to incremental economic burden.

Recent updates in kidney risk prediction modeling: novel approaches and earlier outcomes

PURPOSE OF REVIEW

Recent years have witnessed the development of kidney risk prediction models which diverge from traditional model designs to incorporate novel approaches along with a focus on earlier outcomes. This review summarizes these recent advances, evaluates their pros and cons, and discusses their potential implications.

RECENT FINDINGS

Several kidney risk prediction models have recently been developed utilizing machine learning rather than traditional Cox regression. These models have demonstrated accurate prediction of kidney disease progression, often beyond that of traditional models, in both internal and external validation. On the opposite end of the spectrum, a simplified kidney risk prediction model was recently developed which minimized the need for laboratory data and instead relies primarily on self-reported data. While internal testing showed good overall predictive performance, the generalizability of this model remains uncertain. Finally, there is a growing trend toward prediction of earlier kidney outcomes (e.g., incident chronic kidney disease [CKD]) and away from a sole focus on kidney failure.

SUMMARY

Newer approaches and outcomes now being incorporated into kidney risk prediction modeling may enhance prediction and benefit a broader patient population. However, future work should address how best to implement these models into practice and assess their long-term clinical effectiveness.

Sex Differences in the Recognition, Monitoring, and Management of CKD in Health Care: An Observational Cohort Study

INTRODUCTION

Reported sex differences in the etiology, population prevalence, progression rates, and health outcomes of people with CKD may be explained by differences in health care.

METHODS

We evaluated sex as the variable of interest in a health care-based study of adults (n=227,847) with at least one outpatient eGFR<60 ml/min per 1.73 m2 measurement denoting probable CKD in Stockholm from 2009 to 2017. We calculated the odds ratios for diagnosis of CKD and provision of RASi and statins at inclusion, and hazard ratios for CKD diagnosis, visiting a nephrologist, or monitoring creatinine and albuminuria during follow-up.

RESULTS

We identified 227,847 subjects, of whom 126,289 were women (55%). At inclusion, women had lower odds of having received a diagnostic code for CKD and were less likely to have received RASi and statins, despite having guideline-recommended indications. In time-to-event analyses, women were less likely to have received a CKD diagnosis (HR, 0.43; 95% CI, 0.42 to 0.45) and visited a nephrologist (HR, 0.46; 95% CI, 0.43 to 0.48) regardless of disease severity, presence of albuminuria, or criteria for referral. Women were also less likely to undergo monitoring of creatinine or albuminuria, including those with diabetes or hypertension. These differences remained after adjustment for comorbidities, albuminuria, and highest educational achievement, and among subjects with confirmed CKD at retesting. Although in absolute terms all nephrology-care indicators gradually improved over time, the observed sex gap persisted.

CONCLUSIONS

There were profound sex differences in the detection, recognition, monitoring, referrals, and management of CKD. The disparity was also observed in people at high risk and among those who had guideline-recommended indications.

PODCAST

This article contains a podcast at https://www.asn-online.org/media/podcast/JASN/2022_10_11_JASN2022030373.mp3.

Can SGLT2 inhibitors answer unmet therapeutic needs in chronic kidney disease?

Chronic kidney disease (CKD) is a global health problem, affecting more than 850 million people worldwide. The number of patients receiving renal replacement therapy (dialysis or renal transplantation) has increased over the years, and it has been estimated that the number of people receiving renal replacement therapy will more than double from 2.618 million in 2010 to 5.439 million in 2030, with wide differences among countries. The main focus of CKD treatment has now become preserving renal function rather than replacing it. This is possible, at least to some extent, through the optimal use of multifactorial therapy aimed at preventing end-stage kidney disease and cardiovascular events. Sodium/glucose cotransporter 2 inhibitors (SGLT2i) reduce glomerular hypertension and albuminuria with beneficial effects on progression of renal damage in both diabetic and non-diabetic CKD. SGLT2 inhibitors also show great benefits in cardiovascular protection, irrespective of diabetes. Therefore, the use of these drugs will likely be extended to the whole CKD population as a new standard of care.

Determining the Association Between Continuity of Primary Care and Acute Care Use in Chronic Kidney Disease: A Retrospective Cohort Study

PURPOSE

Acute care use is high among individuals with chronic kidney disease (CKD). It is unclear how relational continuity of primary care influences downstream acute care use. We aimed to determine if poor continuity of care is associated with greater rates of acute care use and decreased prescriptions for guideline-recommended drugs.

METHODS

We conducted a population-based retrospective cohort study of adults with stage 3-4 CKD and ≥3 visits to a primary care clinician during the period April 1, 2011 to March 31, 2014 in Alberta, Canada. Continuity was calculated using the Usual Provider Continuity index. Descriptive statistics were used to summarize patient and acute care encounter characteristics. Adjusted rates and incidence rate ratios for all-cause and CKD-related ambulatory care-sensitive condition (ACSC) hospitalizations and emergency department (ED) visits were estimated using negative binomial regression. Adjusted odds ratios for prescription use were estimated by multivariable logistic regression.

RESULTS

Among 86,475 patients with CKD, 51.3%, 30.0%, and 18.7% had high, moderate, and poor continuity of care, respectively. There were 77,988 all-cause hospitalizations, 6,489 ACSC-related hospitalizations, 204,615 all-cause ED visits, and 8,461 ACSC-related ED visits during a median follow-up of 2.3 years. Rates of all-cause and ACSC hospitalization and ED use increased with poorer continuity of care in a stepwise fashion across CKD stages. Patients with poor continuity were less likely to be prescribed a statin.

CONCLUSIONS

Poor continuity of care is associated with increased acute care use among patients with CKD. Targeted strategies that strengthen patient-physician relationships and guide physicians regarding guideline-recommended prescribing are needed.

Online clinical pathway for chronic kidney disease management in primary care: a retrospective cohort study

BACKGROUND

Clinical pathways aim to improve patient care. We sought to determine whether an online chronic kidney disease (CKD) clinical pathway was associated with improvements in CKD management.

METHODS

We conducted a retrospective pre/post population-based cohort study using linked health data from Alberta, Canada. We included adults 18 years or older with mean estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73m2. The primary outcome was measurement of an outpatient urine albumin creatinine ratio (ACR) in a 28-day period, among people without a test in the prior year. Secondary outcomes included use of guideline-recommended drug therapies (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and statins).

RESULTS

The study period spanned October 2010 to March 2017. There were 84 independent 28-day periods (53 pre, 31 post pathway implementation) including 345,058 adults. The population was predominantly female (56%) with median age 77 years; most had category 3A CKD (67%) and hypertension (82%). In adjusted segmented regression models, the increase in the rate of change of ACR testing was greatest in Calgary zone (adjusted OR 1.19 per year, 95% CI 1.16-1.21), where dissemination of the pathway was strongest; this increase was more pronounced in those without diabetes (adjusted OR 1.25 per year, 95% CI 1.21-1.29). Small improvements in guideline-concordant medication use were also observed.

CONCLUSIONS

Following implementation of an online CKD clinical pathway, improvements in ACR testing were evident in regions where the pathway was most actively used, particularly among individuals without diabetes.

Cost of Potentially Preventable Hospitalizations Among Adults With Chronic Kidney Disease: A Population-Based Cohort Study

BACKGROUND

Prior studies report high hospitalization rates among patients with chronic kidney disease (CKD) and approximately 10% to 20.9% of hospitalizations are potentially preventable.

OBJECTIVE

To determine the rate, proportion, and cost of potentially preventable hospitalizations and whether this varied by CKD category.

DESIGN

Retrospective cohort study using population-based data.

SETTING

Alberta, Canada.

PATIENTS

All adults with an outpatient serum creatinine measurement between January 1 and December 31, 2017 in the Alberta Kidney Disease Network data repository.

MEASUREMENTS

CKD risk categories were based on measures of proteinuria (where available), eGFR, and use of dialysis. Patients were linked to administrative data to capture frequency and cost of hospital encounters and followed until death or end of study (December 31, 2018). The outcomes of interest were the rate and cost of potentially preventable hospitalizations, as identified using the Canadian Institute for Health Information (CIHI)-defined ambulatory care sensitive condition (ACSC) algorithm and a CKD-related ACSC algorithm.

METHODS

Unadjusted and adjusted rates per 1000-patient years, proportions, and cost attributable to preventable hospitalizations were identified for the cohort as a whole and for patients within each CKD risk category.

RESULTS

Of the 1,110,895 adults with eGFR and proteinuria measurements, 181,422 had CKD. During a median follow-up of 1 year, there were 62,023 hospitalizations among patients with CKD resulting in a total cost of $946 million CAD; 6907 (11.1%) of these hospitalizations were for CIHI-defined ACSCs while 4323 (7.0%) were for CKD-related ACSCs. Adjusted rates of hospitalization for ACSCs increased with CKD risk category and were highest among patients treated with dialysis. Among CKD patients, the total cost of potentially preventable hospitalizations was $79 million and $58 million CAD for CIHI-defined and CKD-related ACSCs (8.4% and 6.2% of total hospitalization cost, respectively).

LIMITATIONS

Based on the ACSC construct, we were unable to determine if these hospitalizations were truly preventable.

CONCLUSIONS

Potentially preventable hospitalizations have a substantial cost and burden on the health care system among people with CKD. Effective strategies that reduce preventable admissions among CKD patients may lead to significant cost savings.

TRIAL REGISTRATION

Not applicable-observational study design.

International Society of Nephrology Global Kidney Health Atlas: structures, organization, and services for the management of kidney failure in North America and the Caribbean

The International Society of Nephrology established the Global Kidney Health Atlas project to define the global capacity for kidney replacement therapy and conservative kidney care, and this second iteration was to describe the availability, accessibility, quality, and affordability of kidney failure (KF) care worldwide. This report presents results for the International Society of Nephrology North America and the Caribbean region. Relative to other regions, the North America and Caribbean region had better infrastructure and funding for health care and more health care workers relative to the population. Various essential medicines were also more available and accessible. There was substantial variation in the prevalence of treated KF in the region, ranging from 137.4 per million population (pmp) in Jamaica to 2196 pmp in the United States. A mix of public and private funding systems cover costs for nondialysis chronic kidney disease care in 60% of countries and for dialysis in 70% of countries. Although the median number of nephrologists is 18.1 (interquartile range, 15.3-29.5) pmp, which is approximately twice the global median of 9.9 (interquartile range, 1.2-22.7) pmp, some countries reported shortages of other health care workers. Dialysis was available in all countries, but peritoneal dialysis was underutilized and unavailable in Barbados, Cayman Islands, and Turks and Caicos. Kidney transplantation was primarily available in Canada and the United States. Economic factors were the major barriers to optimal KF care in the Caribbean countries, and few countries in the region have chronic kidney disease-specific national health care policies. To address regional gaps in KF care delivery, efforts should be directed toward augmenting the workforce, improving the monitoring and reporting of kidney replacement therapy indicators, and implementing noncommunicable disease and chronic kidney disease-specific policies in all countries.

Current State and Future of Private Practice Nephrology in the United States

Chronic kidney disease remains highly prevalent and exerts a heavy economic burden. The practice of nephrology has come a long way in managing this disease, though there remains room for improvement. The private domain, where more than half of the adult nephrology workforce operates, faces serious challenges. Interest has decreased in the field, leading to diminished recruitment. There has been a reduction in both reimbursement rates and revenues. We discuss the current state of private practice nephrology and strategies to reinvigorate our discipline. There needs to be a focus on preparing fellows during training not only for academic careers, but also for effective functioning in the environment of private practice and development of pathways for growth. We believe that private practice nephrology must expand its frontiers to be fulfilling professionally, challenging academically, and successful financially. The United States government has recently announced the Advancing American Kidney Health Executive Order which seeks to prioritize optimal treatments for patients with kidney disease. We are optimistic that there is a renaissance afoot in nephrology and that our field is in the process of rediscovering itself, with its best days yet to come.

Developing quality indicators for Chronic Kidney Disease in primary care, extractable from the Electronic Medical Record. A Rand-modified Delphi method

BACKGROUND

Chronic kidney disease (CKD) is a common chronic condition and a rising public health issue with increased morbidity and mortality, even at an early stage. Primary care has a pivotal role in the early detection and in the integrated management of CKD which should be of high quality. The quality of care for CKD can be assessed using quality indicators (QIs) and if these QIs are extractable from the electronic medical record (EMR) of the general physician, the number of patients whose quality of care can be evaluated, could increase vastly. Therefore the aim of this study is to develop QIs which are evidence based, EMR extractable and which can be used as a framework to automate quality assessment.

METHODS

We used a Rand-modified Delphi method to develop QIs for CKD in primary care. A questionnaire was designed by extracting recommendations from international guidelines based on the SMART principle and the EMR extractability. A multidisciplinary expert panel, including patients, individually scored the recommendations for measuring high quality care on a 9-point Likert scale. The results were analyzed based on the median Likert score, prioritization and agreement. Subsequently, the recommendations were discussed in a consensus meeting for their in- or exclusion. After a final appraisal by the panel members this resulted in a core set of recommendations, which were then transformed into QIs.

RESULTS

A questionnaire composed of 99 recommendations was extracted from 10 international guidelines. The consensus meeting resulted in a core set of 36 recommendations that were translated into 36 QIs. This final set consists of QIs concerning definition & classification, screening, diagnosis, management consisting of follow up, treatment & vaccination, medication & patient safety and referral to a specialist. It were mostly the patients participating in the panel who stressed the importance of the QIs concerning medication & patient safety and a timely referral to a specialist.

CONCLUSION

This study provides a set of 36 EMR extractable QIs for measuring the quality of primary care for CKD. These QIs can be used as a framework to automate quality assessment for CKD in primary care.

Incidence and Associations of Chronic Kidney Disease in Community Participants With Diabetes: A 5-Year Prospective Analysis of the EXTEND45 Study

OBJECTIVE

To determine the incidence of and factors associated with an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m² in people with diabetes.

RESEARCH DESIGN AND METHODS

We identified people with diabetes in the EXamining ouTcomEs in chroNic Disease in the 45 and Up Study (EXTEND45), a population-based cohort study (2006-2014) that linked the Sax Institute's 45 and Up Study cohort to community laboratory and administrative data in New South Wales, Australia. The study outcome was the first eGFR measurement <60 mL/min/1.73 m² recorded during the follow-up period. Participants with eGFR < 60 mL/min/1.73 m² at baseline were excluded. We used Poisson regression to estimate the incidence of eGFR <60 mL/min/1.73 m² and multivariable Cox regression to examine factors associated with the study outcome.

RESULTS

Of 9,313 participants with diabetes, 2,106 (22.6%) developed incident eGFR <60 mL/min/1.73 m² over a median follow-up time of 5.7 years (interquartile range, 3.0-5.9 years). The eGFR <60 mL/min/1.73 m² incidence rate per 100 person-years was 6.0 (95% CI 5.7-6.3) overall, 1.5 (1.3-1.9) in participants aged 45-54 years, 3.7 (3.4-4.0) for 55-64 year olds, 7.6 (7.1-8.1) for 65-74 year olds, 15.0 (13.0-16.0) for 75-84 year olds, and 26.0 (22.0-32.0) for those aged 85 years and over. In a fully adjusted multivariable model incidence was independently associated with age (hazard ratio 1.23 per 5-year increase; 95% CI 1.19-1.26), geography (outer regional and remote versus major city: 1.36; 1.17-1.58), obesity (obese class III versus normal: 1.44; 1.16-1.80), and the presence of hypertension (1.52; 1.33-1.73), coronary heart disease (1.13; 1.02-1.24), cancer (1.30; 1.14-1.50), and depression/anxiety (1.14; 1.01-1.27).

CONCLUSIONS

In participants with diabetes, the incidence of an eGFR <60 mL/min/1.73 m² was high. Older age, remoteness of residence, and the presence of various comorbid conditions were associated with higher incidence.

Medication Prescribing Quality in Australian Primary Care Patients with Chronic Kidney Disease

Background: Australian patients with chronic kidney disease (CKD) are routinely managed in general practices with multiple medications. However, no nationally representative study has evaluated the quality of prescribing in these patients. The objective of this study was to examine the quality of prescribing in patients with CKD using nationally representative primary care data obtained from the NPS MedicineWise’s dataset, MedicineInsight. Methods: A cross-sectional analysis of general practice data for patients aged 18 years or older with CKD was performed from 1 February 2016 to 1 June 2016. The study examined the proportion of patients with CKD who met a set of 16 published indicators in two categories: (1) potentially appropriate prescribing of antihypertensives, renin-angiotensin system (RAS) inhibitors, phosphate binders, and statins; and (2) potentially inappropriate prescribing of nephrotoxic medications, such as non-steroidal anti-inflammatory drugs (NSAIDs), at least two RAS inhibitors, triple therapy (an NSAID, a RAS inhibitor and a diuretic), high-dose digoxin, and metformin. The proportion of patients meeting each quality indicator was stratified using clinical and demographic characteristics. Results: A total of 44,259 patients (24,165 (54.6%) female; 25,562 (57.8%) estimated glomerular filtration (eGFR) 45–59 mL/1.73 m²) with CKD stages 3–5 were included. Nearly one-third of patients had diabetes and were more likely to have their blood pressure and albumin-to-creatinine ratio monitored than those without diabetes. Potentially appropriate prescribing of antihypertensives was achieved in 79.9% of hypertensive patients with CKD stages 4–5. The prescribing indicators for RAS inhibitors in patients with microalbuminuria and diabetes and in patients with macroalbuminuria were achieved in 69.9% and 62.3% of patients, respectively. Only 40.8% of patients with CKD and aged between 50 and 65 years were prescribed statin therapy. The prescribing of a RAS inhibitor plus a diuretic was less commonly achieved, with the indicator met in 20.6% for patients with microalbuminuria and diabetes and 20.4% for patients with macroalbuminuria. Potentially inappropriate prescribing of NSAIDs, metformin, and at least two RAS inhibitors were apparent in 14.3%, 14.1%, and 7.6%, respectively. Potentially inappropriate prescribing tended to be more likely in patients aged ≥65 years, living in regional or remote areas, or with socio-economic indexes for areas (SEIFA) score ≤ 3. Conclusions: We identified areas for possible improvement in the prescribing of RAS inhibitors and statins, as well as deprescribing of NSAIDs and metformin in Australian general practice patients with CKD.

Association of Specialist Physician Payment Model With Visit Frequency, Quality, and Costs of Care for People With Chronic Disease

IMPORTANCE

Specialist physicians are key members of chronic care management teams; to date, however, little is known about the association between specialist payment models and outcomes for patients with chronic diseases.

OBJECTIVE

To examine the association of payment model with visit frequency, quality of care, and costs for patients with chronic diseases seen by specialists.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study using propensity-score matching in patients seen by a specialist physician was conducted between April 1, 2011, and September 31, 2014. The study was completed on March 31, 2015, and data analysis was conducted from June 2017 to February 2018 and finalized in August 2019. In a population-based design, 109 839 adults with diabetes or chronic kidney disease newly referred to specialists were included. Because patients seen by independent salary-based and fee-for-service (FFS) specialists were significantly different in observed baseline characteristics, patients were matched 1:1 on demographic, illness, and physician characteristics.

EXPOSURES

Specialist physician payment model (salary-based or FFS).

MAIN OUTCOMES AND MEASURES

Follow-up outpatient visits, guideline-recommended care delivery, adverse events, and costs.

RESULTS

A total of 90 605 patients received care from FFS physicians and 19 234 received care from salary-based physicians. Before matching, the patients seen by salary-based physicians had more advanced chronic kidney disease (2630 of 14 414 [18.2%] vs 6627 of 54 489 [12.2%]), and a higher proportion had 5 or more comorbidities (5989 of 19 234 [31.3%] vs 23 326 of 90 605 [25.7%]). Propensity-score matching resulted in a cohort of 31 898 patients (15 949 FFS, 15 949 salary-based) seeing 489 specialists. In the matched cohort, patients were similar (mean [SD] age, 61.3 [18.2] years; 17 632 women [55.3%]; 29 251 residing in urban settings [91.7%]). Patients seen by salary-based specialists had a higher follow-up visit rate compared with those seen by FFS specialists (1.74 visits; 95% CI, 1.58-1.92 visits vs 1.54 visits; 95% CI, 1.41-1.68 visits), but the difference was not significant (rate ratio, 1.13; 95% CI, 0.99-1.28; P = .06). There was no statistical difference in guideline-recommended care delivery, hospital or emergency department visits for ambulatory care-sensitive conditions, or costs between patients seeing FFS and salary-based specialists. The median association of physician clustering with health care use and quality outcomes was consistently greater than the association with the physician payment, suggesting variation between physicians (eg, median rate ratio for follow-up outpatient visit rate was 1.74, which is greater than the rate ratio of 1.13).

CONCLUSIONS AND RELEVANCE

Specialist physician payment does not appear to be associated with variation in visits, quality, and costs for outpatients with chronic diseases; however, there is variation in outcomes between physicians. This finding suggests the need to consider other strategies to reduce physician variation to improve the value of care and outcomes for people with chronic diseases.

Assessment of the degree of adherence of medical laboratories to KDIGO 2012 guideline for evaluation and management of CKD in Czechia and Slovakia

Introduction

The aim of the study is to assess the degree of adherence of medical laboratories to Kidney Disease Improving Global Outcomes (KDIGO) 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease (CKD) in laboratory practice in Czechia and Slovakia.

Materials and methods

An electronic questionnaire on adherence to KDIGO 2012 guideline was designed by an external quality assessment (EQA) provider SEKK spol. s.r.o. The questionnaire was placed and distributed through website to all medical biochemistry laboratories in Czechia and Slovakia (N = 396).

Results

A total of 212 out of 396 laboratories responded to the questions, though some laboratories only answered some questions, those applicable to their practice. A total of 48 out of 212 laboratories adopted the KDIGO 2012 guideline in full extent. The metrological traceability of creatinine measurement to standard reference material of SRM 967 was declared by 180 out of 210 laboratories (two of the responding laboratories did not measure creatinine). Thirty laboratories are not well educated on traceability of creatinine measurement and seven laboratories do not calculate estimated glomerular filtration rate (eGFR). Both urinary albumin concentration and albumin to creatinine ratio are reported by 144 out of 175 laboratories (37 of the responding laboratories did not measure urinary albumin).

Conclusion

Majority of laboratories in Czechia and Slovakia adopted some parts of the KDIGO 2012 guideline in their practice, but only 23% of the laboratories apply them completely. Thus, further education and action should be conducted to improve its implementation.

Quality of Chronic Kidney Disease Management in Canadian Primary Care

IMPORTANCE

Although patients with chronic kidney disease (CKD) are routinely managed in primary care settings, no nationally representative study has assessed the quality of care received by these patients in Canada.

OBJECTIVE

To evaluate the current state of CKD management in Canadian primary care practices to identify care gaps to guide development and implementation of national quality improvement initiatives.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study leveraged Canadian Primary Care Sentinel Surveillance Network data from January 1, 2010, to December 31, 2015, to develop a cohort of 46 162 patients with CKD managed in primary care practices. Data analysis was performed from August 8, 2018, to July 31, 2019.

MAIN OUTCOMES AND MEASURES

The study examined the proportion of patients with CKD who met a set of 12 quality indicators in 6 domains: (1) detection and recognition of CKD, (2) testing and monitoring of kidney function, (3) use of recommended medications, (4) monitoring after initiation of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs), (5) management of blood pressure, and (6) monitoring for glycemic control in those with diabetes and CKD. The study also analyzed associations of divergence from these quality indicators.

RESULTS

The cohort comprised 46 162 patients (mean [SD] age, 69.2 [14.0] years; 25 855 [56.0%] female) with stage 3 to 5 CKD. Only 4 of 12 quality indicators were met by 75% or more of the study cohort. These indicators were receipt of an outpatient serum creatinine test within 18 months after confirmation of CKD, receipt of blood pressure measurement at any time during follow-up, achieving a target blood pressure of 140/90 mm Hg or lower, and receiving a hemoglobin A1c test for monitoring diabetes during follow-up. Indicators in the domains of detection and recognition of CKD, testing and monitoring of kidney function (specifically, urine albumin to creatinine ratio testing), use of recommended medications, and appropriate monitoring after initiation of treatment with ACEIs or ARBs were not met. Only 6529 patients (18.4%) with CKD received a urine albumin test within 6 months of CKD diagnosis, and 3954 (39.4%) had a second measurement within 6 months of an abnormal baseline urine albumin level. Older age (≥85 years) and CKD stage 5 were significantly associated with not satisfying the criteria for the quality indicators across all domains. Across age categories, younger patients (aged 18-49 years) and older patients (≥75 years) were less likely to be tested for albuminuria (314 of 1689 patients aged 18-49 years [18.5%], 1983 of 11 919 patients aged 75-84 years [61.6%], and 614 of 5237 patients aged ≥85 years [11.7%] received the urine albumin to creatinine ratio test within 6 months of initial estimated glomerular filtration rate <60 mL/min per 1.73 m2; P < .001). Patients aged 18 to 49 years were less commonly prescribed recommended medications (222 of 2881 [7.7%]), whereas patients aged 75 to 84 years were prescribed ACEIs or ARBs most frequently (2328 of 5262 [44.2%]; P < .001).

CONCLUSIONS AND RELEVANCE

The findings suggest that management of CKD across primary care practices in Canada varies according to quality indicator. This study revealed potential priority areas for quality improvement initiatives in Canadian primary care practices.

Capacity of Kidney Care in Canada: Identifying Barriers and Opportunities

BACKGROUND

Chronic kidney disease (CKD) is a significant health problem in Canada. Understanding the capacity of the Canadian health-care system to deliver kidney care is important to provide optimal care.

OBJECTIVE

To compare Canada's position in relation to countries of similar economic standing.

DESIGN

Cross-sectional electronic survey.

SETTING

Member countries of the Organisation for Economic Co-operation and Development (OECD) that participated in the survey.

PARTICIPANTS

Nephrologists, other physicians, policymakers, and other professionals with relevant expertise in kidney care.

MEASUREMENTS

Not applicable.

METHODS

A survey administered by the International Society of Nephrology assessed the global capacity of kidney care delivery. Data from participating OECD countries were analyzed using descriptive statistics to compare Canada's position.

RESULTS

Of the participating countries, most funded kidney care services (non-medication) by government (transplantation: 85%, dialysis: 81%, acute kidney injury (AKI): 77%). Most countries covered medication. Canada reported a public funding model for kidney services and a mix of public and private sources for medication. Nephrologists and nephrology trainee densities were lower in Canada compared to the median (15.33 vs. 25.82 and 1.74 vs. 3.94, respectively). CKD was recognized as a health priority in five countries, but not in Canada. Registries for CKD did not exist in most (24/26) countries. Canada followed a national strategy for noncommunicable diseases, but this was not specific to CKD care, dialysis, or transplantation.

LIMITATIONS

Risks of recall bias or social desirability bias are present. Differences in a number of factors could influence discrepancies among countries and were not explored. Responses reflected the existence of practices, policies, and strategies, and may not necessarily describe action or impact. Capacity of care is not equal across all regions and provinces within Canada; however, the findings are reported on a national level and therefore may not appropriately address variability.

CONCLUSIONS

This study describes the capacity for kidney care at a national level within the context of the Canadian health system. The Canadian health-care system is well funded by the government; however, there are areas that could be improved to increase the optimization of kidney care provided.

Primary care physicians' perceptions of barriers and facilitators to management of chronic kidney disease: A mixed methods study

BACKGROUND

Given the high prevalence of chronic kidney disease (CKD), primary care physicians (PCPs) frequently manage early stage CKD. Nonetheless, there are challenges in providing optimal CKD care in the primary care setting. This study sought to understand PCPs' perceptions of barriers and facilitators to the optimal management of CKD.

STUDY DESIGN

Mixed methods study.

SETTINGS AND PARTICIPANTS

Community-based PCPs in four US cities: Baltimore, MD; St. Louis, MO; Raleigh, NC and San Francisco, CA.

METHODOLOGY

We used a self-administered questionnaire and conducted 4 focus groups of PCPs (n = 8 PCPs/focus group) in each city to identify key barriers and facilitators to management of patients with CKD in primary care.

ANALYTIC APPROACH

We conducted descriptive analyses of the survey data. Major themes were identified from audio-recorded interviews that were transcribed and coded by the research team.

RESULTS

Of 32 participating PCPs, 31 (97%) had been in practice for >10 years, and 29 (91%) practiced in a non-academic setting. PCPs identified multiple barriers to managing CKD in primary care including at the level of the patient (e.g., low awareness of CKD, poor adherence to treatment recommendations), the provider (e.g., staying current with CKD guidelines), and the health care system (e.g., inflexible electronic medical record, limited time and resources). PCPs desired electronic prompts and lab decision support, concise guidelines, and healthcare financing reform to improve CKD care.

CONCLUSIONS

PCPs face substantial but modifiable barriers in providing care to patients with CKD. Interventions that address these barriers and promote facilitative tools may improve PCPs' effectiveness and capacity to care for patients with CKD.

Association of Mental Health Disorders With Health Care Utilization and Costs Among Adults With Chronic Disease

IMPORTANCE

A population-based study using validated algorithms to estimate the costs of treating people with chronic disease with and without mental health disorders is needed.

OBJECTIVE

To determine the association of mental health disorders with health care costs among people with chronic diseases.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study in the Canadian province of Alberta collected data from April 1, 2012, to March 31, 2015, among 991 445 adults 18 years and older with a chronic disease (ie, asthma, congestive heart failure, myocardial infarction, diabetes, epilepsy, hypertension, chronic pulmonary disease, or chronic kidney disease). Data analysis was conducted from October 2017 to August 2018.

EXPOSURES

Mental health disorder (ie, depression, schizophrenia, alcohol use disorder, or drug use disorder).

MAIN OUTCOMES AND MEASURES

Resource use, mean total unadjusted and adjusted 3-year health care costs, and mean total unadjusted 3-year costs for hospitalization and emergency department visits for ambulatory care-sensitive conditions.

RESULTS

Among 991 445 participants, 156 296 (15.8%) had a mental health disorder. Those with no mental health disorder were older (mean [SD] age, 58.1 [17.6] years vs 55.4 [17.0] years; P < .001) and less likely to be women (50.4% [95% CI, 50.3%-50.5%] vs 57.7% [95% CI, 57.4%-58.0%]; P < .001) than those with mental health disorders. For those with a mental health disorder, mean total 3-year adjusted costs were $38 250 (95% CI, $36 476-$39 935), and for those without a mental health disorder, mean total 3-year adjusted costs were $22 280 (95% CI, $21 780-$22 760). Having a mental health disorder was associated with significantly higher resource use, including hospitalization and emergency department visit rates, length of stay, and hospitalization for ambulatory care-sensitive conditions. Higher resource use by patients with mental health disorders was not associated with health care presentations owing to chronic diseases compared with patients without a mental health disorder (chronic disease hospitalization rate per 1000 patient days, 0.11 [95% CI, 0.11-0.12] vs 0.06 [95% CI, 0.06-0.06]; P < .001; overall hospitalization rate per 1000 patient days, 0.88 [95% CI, 0.87-0.88] vs 0.43 [95% CI, 0.43-0.43]; P < .001).

CONCLUSIONS AND RELEVANCE

This study suggests that mental health disorders are associated with substantially higher resource utilization and health care costs among patients with chronic diseases. These findings have clinical and health policy implications.

Prescribing quality in secondary care patients with different stages of chronic kidney disease: a retrospective study in the Netherlands

OBJECTIVES

Insight in the prescribing quality for patients with chronic kidney disease (CKD) in secondary care is limited. The aim of this study is to assess the prescribing quality in secondary care patients with CKD stages 3-5 and possible differences in quality between CKD stages.

DESIGN

This was a retrospective cohort study.

SETTING

Data were collected at two university (n=569 and n=845) and one non-university nephrology outpatient clinic (n=1718) in the Netherlands.

PARTICIPANTS

Between March 2015 and August 2016, data were collected from patients with stages 3a-5 CKD seen at the clinics. Blood pressure measurements, laboratory measurements and prescription data were extracted from medical records. For each prescribing quality indicator, patients with incomplete data required for calculation were excluded.

OUTCOME MEASURES

Potentially appropriate prescribing of antihypertensives, renin-angiotensin-aldosterone system (RAAS) inhibitors, statins, phosphate binders and potentially inappropriate prescribing according to prevailing guidelines was assessed using prescribing quality indicators. Χ² or Fisher's exact tests were used to test for differences in prescribing quality.

RESULTS

RAAS inhibitors alone or in combination with diuretics (57% or 52%, respectively) and statins (42%) were prescribed less often than phosphate binders (72%) or antihypertensives (94%) when indicated. Active vitamin D was relatively often prescribed when potentially not indicated (19%). Patients with high CKD stages were less likely to receive RAAS inhibitors but more likely to receive statins when indicated than stage 3 CKD patients. They also received more active vitamin D and erythropoietin-stimulating agents when potentially not indicated.

CONCLUSIONS

Priority areas for improvement of prescribing in CKD outpatients include potential underprescribing of RAAS inhibitors and statins, and potential overprescribing of active vitamin D. CKD stage should be taken into account when assessing prescribing quality.

Patient and provider experience and perspectives of a risk-based approach to multidisciplinary chronic kidney disease care: a mixed methods study

BACKGROUND

The Kidney Failure Risk Equation (KFRE) predicts risk of progression to kidney failure and is used to guide clinical decisions for patients with chronic kidney disease (CKD).

METHODS

The KFRE was implemented to guide access to multidisciplinary care for CKD patients in Alberta, Canada, based on their 2-year risk of kidney failure. We used a mixed methods approach to investigate patients' and providers' perspectives and experiences 1 year following KFRE implementation. We conducted post-implementation interviews with multidisciplinary clinic providers and with low-risk patients who transitioned from multidisciplinary to general nephrology care. We also administered pre- and post-implementation patient care experience surveys, targeting both low-risk patients discharged to general nephrology and high-risk patients who remained in the multidisciplinary clinic, and provider job satisfaction surveys.

RESULTS

Twenty-seven interviews were conducted (9 patients, 1 family member, 17 providers). Five categories were identified among patients and providers: targeted care; access to resources outside the multidisciplinary clinics; self-efficacy; patient reassurance and reduced stress; and transition process for low-risk patients Two additional categories were identified among providers only: anticipated concerns and job satisfaction. Patients and providers reported that the risk-based approach allowed the clinic to target care to those most likely to experience kidney failure and most likely to benefit from multidisciplinary care. While some participants indicated the risk-based model enhanced the sustainability of the clinics, others expressed concern that care for low-risk patients discharged from multidisciplinary care, or those now considered ineligible, may be inadequate. Overall, 413 patients completed the care experience survey and 73 providers completed the workplace satisfaction survey. The majority of patients were satisfied with their care in both periods with no overall differences. When considering the responses "Always" and "Often" together versus not, there were statistically significant improvements in domains of access to care, caring staff, and safety of care. There were no differences in healthcare providers' job satisfaction following KFRE implementation.

CONCLUSIONS

Patients and healthcare providers reported that the risk-based approach improved the focus of the multidisciplinary CKD clinics by targeting patients at highest risk, with survey results suggesting no difference in patient care experience or healthcare provider job satisfaction.

Long-term views on chronic kidney disease research priorities among stakeholders engaged in a priority-setting partnership: A qualitative study

BACKGROUND

Patients and stakeholders are increasingly engaging in health research to help address evidence-practice gaps and improve health-care delivery. We previously engaged patients, caregivers, health-care providers (HCPs) and policymakers in identifying priorities for chronic kidney disease (CKD) research.

OBJECTIVE

We aimed to explore participants' views on the research priorities and prioritization process 2 years after the exercise took place.

DESIGN

In this qualitative descriptive study, individual interviews were conducted and analysed using an inductive, thematic analysis approach.

SETTING/PARTICIPANTS

Participants resided across Canada. We purposively sampled across stakeholder groups (CKD patients, caregivers, HCPs and policymakers) and types of engagement (wiki, workshop and/or steering committee) from the previous CKD priority-setting project.

RESULTS

Across 23 interviews, participants discussed their research priorities over time, views on the prioritization process and perceived applicability of the priorities. Even though their individual priorities may have changed, participants remained in agreement overall with the previously identified priorities, and some perceived a distinction between patient and HCP priorities. They tended to balance individual priorities with their broader potential impact and viewed the prioritization process as systematic, collaborative and legitimate. However, participants acknowledged challenges to applying the priorities and emphasized the importance of communicating the project's outcomes upon its completion.

CONCLUSION

Two years after engaging in CKD research prioritization, stakeholder participants remained in agreement with the previously identified priorities, which they felt reflected group deliberation and consensus. Rapport and communication were highlighted as key elements supporting effective engagement in research prioritization.

Impact of a Primary Care CKD Registry in a US Public Safety-Net Health Care Delivery System: A Pragmatic Randomized Trial

BACKGROUND

Many individuals with chronic kidney disease (CKD) do not receive guideline-concordant care. We examined the impact of a team-based primary care CKD registry on clinical measures and processes of care among patients with CKD cared for in a public safety-net health care delivery system.

STUDY DESIGN

Pragmatic trial of a CKD registry versus a usual-care registry for 1 year.

SETTING & PARTICIPANTS

Primary care providers (PCPs) and their patients with CKD in a safety-net primary care setting in San Francisco.

INTERVENTION

The CKD registry identified at point of care all patients with CKD, those with blood pressure (BP)>140/90mmHg, those without angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB) prescription, and those without albuminuria quantification in the past year. It also provided quarterly feedback pertinent to these metrics to promote "outreach" to patients with CKD. The usual-care registry provided point-of-care cancer screening and immunization data.

OUTCOMES

Changes in systolic BP at 12 months (primary outcome), proportion of patients with BP control, prescription of ACE inhibitors/ARBs, quantification of albuminuria, severity of albuminuria, and estimated glomerular filtration rate.

RESULTS

The patient population (n=746) had a mean age of 56.7±12.1 (standard deviation) years, was 53% women, and was diverse (8% non-Hispanic white, 35.7% black, 24.5% Hispanic, and 24.4% Asian). Randomization to the CKD registry (30 PCPs, 285 patients) versus the usual-care registry (49 PCPs, 461 patients) was associated with 2-fold greater odds of ACE inhibitor/ARB prescription (adjusted OR, 2.25; 95% CI, 1.45-3.49) and albuminuria quantification (adjusted OR, 2.44; 95% CI, 1.38-4.29) during the 1-year study period. Randomization to the CKD registry was not associated with changes in systolic BP, proportion of patients with uncontrolled BP, or degree of albuminuria or estimated glomerular filtration rate.

LIMITATIONS

Potential misclassification of CKD; missing baseline medication data; limited to study of a public safety-net health care system.

CONCLUSIONS

A team-based safety-net primary care CKD registry did not improve BP parameters, but led to greater albuminuria quantification and more ACE inhibitor/ARB prescriptions after 1 year. Adoption of team-based CKD registries may represent an important step in translating evidence into practice for CKD management.

Delivering a "New Deal" of Kidney Health Opportunities to Improve Outcomes Within the Veterans Health Administration

Just as the "New Deal" aimed to elevate the "forgotten man" of the Great Depression through governmental relief and reform, so does the Department of Veterans Affairs (VA) health care system aim to improve the health of veterans with the invisible illness of chronic kidney disease through a concerted series of health care delivery reforms. Augmenting its primary care platform with advances in informatics and health service delivery initiatives targeting kidney disease, the VA is changing how nephrology care is provided to veterans with the goal of optimized population kidney health. As the largest provider of kidney health services in the country, the VA offers an instructive case study of the value of comprehensive health care coverage for people with chronic kidney disease. Recent reports of kidney health outcomes among veterans support the benefit of the VA's integrated health care delivery system. Suggestions to optimize veterans' kidney health further may be equally applicable to other health systems caring for people afflicted with kidney disease.

Perceived Benefits and Challenges of a Risk-Based Approach to Multidisciplinary Chronic Kidney Disease Care: A Qualitative Descriptive Study

Background:

The kidney failure risk equation (KFRE) provides an estimate of risk of progression to kidney failure, and may guide clinical care.

Objective:

We aimed to describe patient, family, and health care provider’s perspectives of the perceived benefits and challenges of using a risk-based approach to guide care delivery for patients with advanced chronic kidney disease (CKD), and refine implementation based on their input.

Methods:

We used qualitative methodology to explore perceived benefits and challenges of implementing a risk-based approach (using the KFRE) to determine eligibility for multidisciplinary CKD care in Southern Alberta. We obtained perspectives from patients and families through focus groups, as well as input from health care providers through interviews and open-ended responses from an online survey. Twelve patients/family members participated in 2 focus groups, 16 health care providers participated in an interview, and 40 health care providers responded to the survey.

Results:

Overall, participants felt that a KFRE-based approach had the potential to improve efficiency of the clinics by targeting care to patients at highest risk of kidney failure; however, they also expressed concerns about the impact of loss of services for lower risk individuals. Participants also articulated concerns about a perceived lack of capacity for adequate CKD patient care in the community. Our implementation strategy was modified as a result of participants’ feedback.

Conclusions:

We identified benefits and challenges to implementation of a risk-based approach to guide care of patients with advanced CKD. Based on these results, our implementation strategy has been modified by removing the category of referral back to primary care alone, and instead having that decision made jointly by nephrologists and patients among low-risk patients.

Implementation and Evaluation of a Risk-Based Approach to Guide Chronic Kidney Disease Care: Protocol for a Multiphase Mixed-Methods Study

Background

Risk prediction tools are used in a variety of clinical settings to guide patient care, although their use in chronic kidney disease (CKD) care is limited.

Objectives

To assess the association of a risk-based model of CKD care on patient care, satisfaction, outcomes, and cost.

Design

Mixed-methods with a pre-post design.

Setting

We will use mixed-methods and a pre-post design to evaluate use of the Kidney Failure Risk Equation (KFRE) to guide CKD care. The KFRE will be applied to patients currently followed in nephrology multidisciplinary CKD clinics in Alberta, as well as to new patients being considered for multidisciplinary care.

Patients

Patients with a 2-year risk of kidney failure ≥10% or estimated glomerular filtration rate (eGFR) ≤15 mL/min/1.73 m² will be recommended care by a multidisciplinary team coordinated by a nurse clinician and nephrologist, with access to other multidisciplinary resources including dietitians, pharmacists, and social workers as required.

Measurements/Methods

Focus groups and interviews will be conducted to qualitatively describe patient and provider perspectives of potential barriers and facilitators to implementation of the risk-based approach to CKD care. Patient and provider surveys will also be used to quantify patient and provider satisfaction before and after the intervention. Finally, administrative data will be used to evaluate the association between the risk-based approach to care and outcomes including health care resource use, frequency of testing, modality choice, and death.

Conclusions

Use of a risk-based model of care has the potential to increase use of optimal treatments such as the use of home dialysis and preemptive kidney transplantation, while reducing costs and poor outcomes related to processes of care such as unnecessary laboratory testing; however, there is also potential for unintended consequences. Our mixed-methods approach will integrate perceptions and needs from key stakeholders (including patients with CKD, their families, and their providers) to guide implementation and ensure appropriate modifications.