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Referral of High- and Low-Risk Groups in DKD


Aida Vega, MD, and Fernando Carnavali, MD, discuss the KidneyIntelX study and the rates of referrals of high-risk DKD patients to specialist care.

Aida Vega, MD: Let's talk a bit about some of the other differences that we saw in terms of referrals in the high-risk and the low-risk patients.

Fernando Carnavali, MD: When I was reviewing the study it was striking to me, one of the things we know is that the percentage of patients who have taken action within 6 months was dramatic. And again, from the high-risk to the intermediate and the low-risk. So, we have something being done. And as we said before, many of these patients go all the way into end-stage and hemolysis without intervention. So, having a tool that all of a sudden takes you to a different place is important. The other thing that we know is the percentage of patients seen by the primary care in the first month. And again, pointing to the fact that the tool creates this awareness that, as you mentioned before, we know that obviously perhaps the high-risk group was the group taking the lead in this percentage of patients seen within 1 month and followed by the intermediate-risk group. If you combine those 2, we're talking a healthy percentage of patients reaching their primary care within 30 days. This is important data to know and to take a different angle and how to evaluate that a new tool that is perceived by the providers as robust creates changes in the way that people practice their medicine.

Aida Vega, MD: And as you said, these patients, again, the high-risk patients were seen within the first month, 49% of them. And many as we participated in this, you know very well that these patients would've just had a urine albumin-creatinine ratio and an EGFR that may not have been salient at all to any of us. But all of a sudden, we had the intermediate- or high- risk [patient] and said, oh my goodness, we need to bring this person back. And we ended up bringing many of the, or at least the providers who were in this study brought, patients back, as you said, within the first month. And it started to engage the patient’s conversation about their risk, which is also an important part of the study. And then the actions taken, these patients may not have been seen again for 6 months or in a year, but within 6 months there were actions taken such as starting them on medications or maximizing their medications. So, intermediate- and high-risk patients were mostly impacted, but you saw that everyone was seen more often within the first 6 months. Can you comment on how the KidneyIntelX score informed providers on the need for specialist care?

Fernando Carnavali, MD: The impact of having the score guiding, and we are talking about care pathways, how the score is not isolated and that’s that, but there’s a guidance on what you do, the suggestion of what to look at as the best practice and as the best next steps. That's what makes these particular tools, what makes KidneyIntelX, even more attractive. The pathway is there. And that's not surprising that we are seeing the next steps. The slide that we're looking at now also points out to the fact that any screening tests like KidneyIntelX and—but any in my view of in primary care that will include EHR data—lab data and that will go then through the machine learning; we’ll have the primary care physicians as the goalkeepers. It will be where everything will start. And we're seeing here 61% of the primary care providers were the ones ordering that. And as we said before, more following of the guidelines, more appropriate subspecialty consults, changes in the medications, all these 3 items, as we can see on the slide, have improved in different levels, but they all have improved. And that's something that we haven't seen with any of the other tools that have been used in the past.

Aida Vega, MD: Yes. As we see in this slide, the patients who were high-risk were more likely to have specialist consultation. And this also reiterates the fact that the primary care provider and the specialists need to work together collaboratively to treat these patients who are intermediate- and high-risk. So, the study showed that this occurred. And again, highlighting in our population that we sometimes don't refer patients appropriately or in a timely fashion to our specialist colleagues. Let's go back a bit about what we did. For the patients who were in—across the board, but especially the patients who were intermediate-risk or high-risk,—were 4 and a half times more likely to start SLGT-2s [sodium-glucose cotransporter 2], the GLP-1s [glucagon-like peptide], or improve their treatment guidelines. And then we also spend 2 and a half times more specialty referrals for these patients, especially the ones at high risk. And what was most interesting is that we modify their antihypertensives 1 and a half times they are more likely to modify their ACE [angiotensin-converting enzyme] inhibitors, either starting them on ACE or ARBs [angiotensin II receptor blockers], or maximizing their control. Guideline-based care in a tool that identifies patients who are going to progress to kidney failure or advance in their kidney disease impacted what the providers did, especially the primary care physicians in terms of following treatment-based guidelines.

Fernando Carnavali, MD: Yes. And to the point, and I completely agree with you. When we think about kidneys, they're not isolated organs and we know the impact that we have in the heart and all the other organs. This is not an isolated item. So, seeing these and the correction of abnormal blood pressure values is important. And as we mentioned before, the increase in the use of the SGLT-2 inhibitors is extremely important. We cannot highlight enough that our understanding is getting better at how these agents work. And it's not only when talking about glucose, but also talking about the anti-inflammatory characteristics of the agents, the hemodynamically changes that happens when you take this medication. So, it's important to see this change that was created by having a score, having a prediction that was brought by the KidneyIntelX. Very important.

Aida Vega, MD: Many primary care physicians are uncomfortable to start the patients on the novel therapies like the SGLT-2 and it made them comfortable with using the drugs as well. So, it not only highlighted that these patients who were at risk and needed to have these novel therapies started based on the American Diabetes Association Guidelines, but also with increased use it made them comfortable with that class, made them comfortable with that class of drugs.

Fernando Carnavali, MD: Yes, I’m in agreement with you. And we know the studies with heart failure and the same group of medications. So, data continues to reassure ourselves the value of this. And then there were some questions from the primary care group from us about the costs and who we cover, and some of the preapprovals. As we're using it more, we are learning more about what will have more likelihood of being approved and creating the mechanisms to secure the prescriptions to our patients.

Aida Vega, MD: I agree that the fact that these guidelines are not just for kidney disease, they are also for heart failure, preventing cardiovascular outcomes that we see in the diabetic patients. As the primary care physicians continue to prescribe these novel therapies to prevent negative outcomes in diabetics with kidney disease, I feel like this will encourage the insurance companies and other providers of care to be able to make it more equitable across all populations.

Fernando Carnavali, MD: And that is the hope, certainly.

Transcript edited for clarity

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