During the learning and action workgroups, stakeholders identified several barriers to CKD testing, diagnosis, and management.
Knowledge and Awareness: There is a general lack of CKD knowledge and awareness across multiple stakeholders. Among the public and patients, the risk factors for CKD are not well known. Therefore, patients are not knowledgeable when to get tested, and even if patients are tested, they are not equipped with the chronic disease self-management tools needed to handle their diagnosis. Patients need better access to information or tools to help manage medications, navigate referrals to specialists, access to mental health support, and make diet or lifestyle changes to manage CKD. Challenges with health literacy and navigating a complex health system compound this issue.
Among clinicians there are awareness gaps around the guidelines for screening, the impact of CKD on health outcomes, especially cardiovascular outcomes, and the costs of CKD. Limited appreciation of the role of social determinants of health in CKD also hampers appropriate intervention. Disparities in CKD will not be addressed without recognition and action to address these root causes.
Health Care Systems and Structures: Competing priorities and limited clinician time in primary care are significant barriers. Multiple quality measures and chronic condition care guidelines can be overwhelming. Additionally, EMR tools and technology are not optimized for CKD, making it easy for clinicians to lose sight of CKD testing and management. Participating group members agreed that providing the best care to patients is done most effectively with an interdisciplinary team. However, primary care teams lack the structure or bandwidth to successfully implement new initiatives.
Incentives and Quality Measures: Early detection and treatment of CKD needs more attention, with emphasis on economic savings, cost-benefit studies and incentives for providers and patients. Outcome measures are not clear or agreed upon and value-based incentives for CKD screening are not prioritized.
To address these barriers, stakeholders identified fourteen recommendations, across five themes to serve as a roadmap for Greater New York to improve testing, diagnosis, and management of CKD.