revolutionizing renal care with predictive analytics for ckd
TRANSCRIPT
Revolutionizing Renal Care with Predictive Analytics for CKD
Navdeep Tangri, MD, PhD, FRCP(C)Eleanor Herriman, MD, MBADave Garnett
May 10, 2016
Navdeep Tangri, M.D. Ph.D. FRCP(C)
• Developed and validated the Kidney Failure Risk Equation
• Has published more than 120 manuscripts and presented at several national and international scientific meetings
• Reviews manuscripts for several major medical journals
• Section Editor of Current Opinion in Nephrology and Hypertension• Has active grants from the Canadian Institute of Health Research,
Kidney Foundation of Canada, and Manitoba Health Research Council
Attending Physician, Associate Professor, Division of Nephrology, Department ofMedicine, University of Manitoba: Director, Chronic Disease Innovation Center,Seven Oaks Hospital
• Co-chairs the scientific committee of the Canadian Society of Nephrology
• Member of the American Society of Nephrology and the International Society of Nephrology
L. Eleanor J. Herriman, M.D.,M.B.A.
• Physician executive with 20 years of varied healthcare experience
• Former faculty member at Harvard Business School’s Institute for Strategy and Competitiveness
• Market research and strategy services to the pathology and laboratory industries at G2 Intelligence
• Healthcare strategy consulting at Bain & Company
Education• Doctor of Medicine degree from Baylor College of Medicine• Presidents Scholarship with honors in Neurology, Psychiatry and
Neuropathology
• Masters in Business Administration from Harvard University Graduate School of Business Administration as a Baker Scholar
Chief Medical Informatics Officer, Viewics
Dave Garnett
• Multi-time entrepreneur and recognized authority on cloud computing, Big Data analytics, and entrepreneurship
• Leads product management, product marketing, and user experience• Formerly held senior executive management positions at Actuate
Corporation, Gluster, and 24-7 Customer
• Founder of Axcient, Digital Data Storage, and Feedheed
• Studied Philosophy at Santa Clara University
VP of Products, Viewics
Agenda
• Chronic Kidney Disease – The Problem (Eleanor Herriman)
• The Kidney Failure Risk Equation – A New Solution (Navdeep Tangri)
• Viewics CKD Management – A KFRE Program (Dave Garnett)
• Discussion and Q&A
The CKD Problem
About CKD
Characterized by a gradual loss of kidney function over time
Diagnosis - kidney damage (albuminuria) or
decreased kidney function (GFR <60) for 3
months+
Diabetes and hypertension responsible for two-thirds of cases
Increased risk of cardiovascular disease –heart complications
major cause of death for CKD patients
Early detection and treatment can often slow
progression vs. progression to end stage
failure (dialysis or transplant)
Source: National Kidney Foundation (NKF) and Lancet 2012;; 379: 165–80
CKD High Incidence and Prevalence
54%
44%
40%Prevalence in Diabetics
Prevalence Over 65 yrs
U.S. Lifetime Incidence for 30 - 49 yrs
26M in U.S.
Source: NKF and Hoerger TJ et al. Am J Kidney Dis. 2015;;65(3):403-411
Morbidity and Mortality
CKD Cardiovascular disease
Risk factor for medical errors
Acute kidney injury
Anemia
Bone disorders
Nervous system / CNS (malnutrition)
Economic Burden - Medicare
$48 B
$33 B
0
10
20
30
40
50
60
CKD ESRD
2010 CMS Spend In U.S. $B
Source: Hoerger TJ et al. Am J Kidney Dis. 2015;;65(3):403-411
Economic Burden - Private
$25 K
$46 K
05101520253035404550
Stage 3 CKD Stage 4 CKD
2015 Private Payer Spend Per Patient $K
Workdays missed exceed 10 hours per week for employees with CKD
Traditional CKD Management –Stages by Glomerular Filtration Rate (GFR)
• PCP• “Low risk”• Very low awareness of disease
Stage 1-2
• Variability in nephrologist referral• Effective Rx available • Progression unpredictable
Stage 3 • Nephrologist• Significant numbers actually lower risk
Stage 4
• Discuss dialysis options / implant fistula• 66% of ESRD not referred in time for dialysis
Stage 5
The Volume – Risk Dilemma
Young Patients
Higher Risk of Progressing
Few Patients with CKD
Risk
Volume
Elderly
Most at Low Risk of Progressing
Many Patients with CKD(50% over 70 yo)
Risk
Volume
Need Predictive Model to Identify Progressors
Current CKD Management Suboptimal
“With current treatment, nearly half of patients progress tounfavorable renal and cardiovascular outcomes. … Attention totraditional measures of kidney function (eg, eGFR) is no longeradequate to optimally manage and care for patients with CKD.”
Lee Ann Braun et al., RTI Health Solutions, Ann Arbor, MI, and Mitsubishi Tanabe Pharma America, Inc,
Warren, NJ, USA
Source: International Journal of Nephrology and Renovascular Disease 2012:5 151–163
Challenges of CKD
Patients diagnosed later in disease spectrum –poor awareness
High variability of condition and patient risk of progression – difficult
to manage
Treatments and specialty care can impact
outcomes, but must be targeted appropriately
(clinical and $)
Kidney Failure Risk Equation
Why CKD risk prediction
• Early and appropriate nephrology care
• Prognostic Information for patient and provider
• Clinical trial enrollment
• Dialysis resource management
Source: Tangri et al. Curr Opinion Nephrology Hypertension 2013
Care for Advanced CKD• Progression challenges
– Not all patients with CKD Stage 4 progress
– Some patients with CKD Stage 3 are at a higher risk for progression
• Managing care by GFR– GFR based care for advanced CKD misses the mark– Care should be aligned with risk rather than eGFR
• Complexity of advanced care– Patients with CKD Stages 4-5 are at high risk of adverse events including progression to
kidney failure– Advanced care patients need education about treatment options, modality planning and
specialized nutrition
– Interdisciplinary care in clinics is delivered by health care teams (nurses, dieticians, pharmacist & nephrologist) - $ 1600 annually
Ideal Model
• Across spectrum of chronic kidney disease
• Electronic ascertainment and reporting
• Improve discrimination and reclassification beyond standard of care
• Externally validated in diverse patient populations
Source: Tangri et al. Annals of Internal Medicine 2013
Published Online FirstApril 11, 2011
Available atwww.jama.com
A prediction model for progression of CKD to Kidney Failure
• Patients with CKD Stages 3 – 5
• Followed by nephrologists in Ontario and British Columbia, Canada
• 8,391 participants with 1,563 kidney failure events
• Multiple lab based prediction models
Risk Prediction Models
Kidney Failure Risk Equation (KFRE)
• We developed laboratory based prediction models that accurately predict the progression of CKD (C statistics 0.84 – 0.91)
• Our preferred models use routinely collected laboratory data– 3 variable KFRE – Age, Sex, eGFR– 4 variable KFRE – Age, Sex, eGFR, ACR– 8 variable KFRE – + Calcium, Phosphorous, Bicarbonate and Albumin
Source: Tangri et al. JAMA 2011
External Validation
• Initially valid in two Canadian cohorts of patients referred to nephrologists
• Concerns re: validity in other ethnicities and health systems
• External validation needed prior to global adoption
Tangri et al. JAMA 2016
Study Design
• A validation study of the KFRE in patients with CKD 3-5 (referred and unreferred) from the CKD Prognosis Consortium (CKD-PC)
• Individual level meta-analysis of beta coefficients, discrimination, calibration and net reclassification improvement
• Individual-study and pooled measures of model validation
Discrimination
Ontario Renal Network and KFRE
• ORN– Responsible for providing all dialysis and advanced CKD care in the province of Ontario, Canada
– Includes 11,000 patients on dialysis, and 17,000 patients with advanced CKD– Annual budget exceeds $ 640 million
• Plan for implementing KFRE– Adopt risk based thresholds as eligibility criteria for interdisciplinary care – Align level of risk with intensity of care– Cost savings of $ 1300 annually per patient– Annualized savings of $ 7 million for the ORN
Conclusions
• The KFREs accurately predict the risk of kidney failure requiring dialysis in patients with CKD Stages 3-5 for up to 5 years
• Risk prediction is accurate across multiple countries and subpopulations
• The equation is simple and highly accurate and can be integrated into clinical practice
Viewics CKD Management™
Viewics CKD Management™ – Care Protocol
Risk score > xx%* over 5 years• Refer from PCP to nephrologist
Risk score > yy%* over 2 years• Refer to multidisciplinary clinic / hospital support
Risk score > zz%* over 2 years• Discuss dialysis / transplants preparations
Risk score > aa%* over 2 years• Place AVF fistula
* Exact thresholds provided to Viewics customers only
• Alerts on at risk patients who have not been referred to Nephrologists
• View all CKD patients you provide care for
• Create and send a customized report to the patient– Where they are with disease
progression– Treatment options
– Information about the disease
Viewics CKD Management™: Sample Dashboard - Physician View
• Dashboard showing entire population of CKD patients under their care, their staging information, and their risks of ESRD
• Stoplight for low / medium /high risk
• Alerts for high risk patients • Most recent risk score and date
of testing • Determination of whether or not
care protocol has been followed• Provides traditional staging for
reference
Viewics CKD Management™: Sample Dashboard - Nephrologist View
Source: Navdeep Tangri, MD, FRCPC, http://kidneyfailurerisk.com/
Viewics CKD Management™: Sample Report - Patient View
Viewics CKD Management™: Sample Dashboard - Executive View
• View Patients by Risk• Make sure your PCPs are
following the care protocol• Track where patients are
within the system• See trends on CKD
throughout the system• Benchmark against other
systems*• View to date & projected
savings*
Viewics CKD Management™ - Benefits
BENEFITS TO PATIENTS, CLINICIANS AND HEALTH
Personalized risk scores with care management and patient education reports lower patient anxiety levels and improve PCP care.
More appropriate and earlier nephrologist care translates to better patient choices, fewer emergency cases, lower costs, better outcomes.
More accurate and standardized risk prediction improves resource utilization, generating savings. Inaccurate CKD staging causes over and under-treatment, driving avoidable costs and adverse events.
Validated risk thresholds provide care management pathways. PCPs directed to refer to nephrologists, and nephrologists to discuss dialysis, thus slowing progression and improving Renal Failure outcomes.
Sources: Tangri N et al. JAMA. 2016;;315(2):164-174;; Personal communication with Navdeep Tangri, MD, FRCPC;; Lee et al. BMC Health Services Research 2012, 12:252;; Lee J, et al. (2014) PLoS ONE 9(6): e99460.
Viewics CKD Management™ – Expected Savings
$800K savings
Better care slows progression to 3b
$1M savings
Risk scores change 30% of Stage 4s to Stage 3
$210K savings
Helps decrease necessity of dialysis/transplant for patients
Delay in Stage 3 Progression
ReclassifyingStage 4
Earlier Nephrologist Care Pre-Renal Failure
Sources: Tangri N et al. JAMA. 2016;;315(2):164-174;; Personal communication with Navdeep Tangri, MD, FRCPC;; Lee et al. BMC Health Services Research 2012, 12:252;; Lee J, et al. (2014) PLoS ONE 9(6): e99460;; Reaven NL et al. Am J Pharm Benefits. 2014;;6(6):e169-e176.
Total Savings for Health System with Population of 25,000 ~ $2M
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For further information and resources on this topic, please visit renalrisk.com