Population Health Management and Guideline-Concordant Care in CKD
Authors: Weltman Melanie R. , Lavenburg Linda-Marie U. , Han Zhuoheng , Alghwiri Alaa A. , Mosslemi Mitra , Rollman Bruce L. , Fischer Gary S. , Nolin Thomas D. , Yabes Jonathan G. , Jhamb Manisha 
Published: November 2024

Key Points

Implementation gaps in guideline-concordant care for CKD are associated with poor clinical outcomes.A population health management–based, multidisciplinary approach improved exposure days to sodium-glucose cotransporter-2 inhibitor and glucagon-like peptide-1 receptor agonists compared with usual care.Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker in albuminuric patients and statin use was not improved, nor was BP control, glycemic control, or albuminuria testing.

Background
Gaps in guideline-concordant care for CKD lead to poor outcomes. The Kidney Coordinated HeAlth Management Partnership (K-CHAMP) cluster randomized trial tested the effect of a population health management intervention versus usual care on CKD progression and evidence-based care delivery in the primary care setting.

Methods
K-CHAMP included adults aged 18–85 years with eGFR<60 ml/min per 1.73 m2 and moderate-high risk of CKD progression who were not seeing a nephrologist. The multifaceted intervention included nephrology e-consult, pharmacist-led medication management, and patient education. In this post hoc analysis, we evaluate the effectiveness of K-CHAMP on guideline-concordant care processes (BP and glycemic control, annual albuminuria testing) and medication exposure days (angiotensin-converting enzyme inhibitor [ACEi]/angiotensin receptor blocker [ARB], moderate-high intensity statin, sodium-glucose cotransporter-2 inhibitor [SGLT2i], glucagon-like peptide-1 receptor agonists [GLP-1RA]). Given multiplicity of outcomes, Benjamini–Hochberg method was used to control false discovery rate.

Results
All 1596 (754 intervention, 842 usual care) enrolled patients (mean age 74±9 years, eGFR 37±8 ml/min per 1.73 m2, 928 [58%] female, 127 [8%] Black) were analyzed. After a median 17-month follow-up, intervention arm patients had significantly higher exposure days per year to SGLT2i (56 versus 32 days; relative benefit 1.72; 95% confidence interval [CI], 1.14 to 2.30) and GLP-1RA (78 versus 29 days; relative benefit 2.65; 95% CI, 1.59 to 3.71) compared with usual care in adjusted analysis. At study initiation in 2019, similar proportion of patients were prescribed SGLT2i and/or GLP-1RA in intervention and control arm (8% versus 6%, respectively; rate ratio 1.23; 95% CI, 0 to 2.99), but by 2022, prescription of these medications was significantly higher in intervention arm (44% versus 27%, respectively; rate ratio 1.63; 95% CI, 1.32 to 1.94). There was no significant difference in any process measures or exposure days to ACEi/ARB in patients with albuminuria or moderate-high intensity statin.

Conclusions
K-CHAMP was effective in accelerating implementation of SGLT2i and GLP-1RA but did not increase ACEi/ARB in patients with albuminuria or moderate-high intensity statin use or improve BP control, glycemic control, or albuminuria testing in individuals with CKD in the primary care setting.

Clinical Trial registry name and registration number:
K-CHAMP, NCT03832595.