Population Health Management Expands Value-Based Kidney Care
Key Clinical Summary
- Chronic kidney disease (CKD) affects 33.5 million US adults and drives substantial morbidity, mortality, and $137 billion in Medicare spending, with gaps in guideline-based care contributing to disease progression.
- A population health management (PHM) model using electronic health records and multidisciplinary teams improved care processes, including medication optimization and access to specialty services.
- Early-stage CKD intervention and scalable PHM programs may support value-based care and reduce disparities across the kidney disease continuum.
CKD remains a major public health burden in the US, affecting approximately 15% of adults and contributing to high health care utilization and costs. A perspective from the University of Pittsburgh Medical Center (UPMC) describes how population health management (PHM) strategies may improve CKD outcomes through data-driven, scalable care models.
Study Findings
The authors outline a PHM approach designed to address persistent gaps in CKD care, including delayed diagnosis, inadequate treatment, and fragmented care delivery. These gaps contribute to disease progression, hospitalizations, and mortality, particularly among socioeconomically disadvantaged populations.
At UPMC, investigators developed an electronic health record–based CKD registry capturing more than 157 000 patients. The registry integrates laboratory data, medications, and risk stratification tools such as the Kidney Failure Risk Equation to identify high-risk individuals and guide interventions.
A key intervention, the Kidney Coordinated Health Management Partnership (K-CHAMP), used a multidisciplinary model combining automated nephrology e-consults, pharmacist-led medication management, and nurse-led patient education. In a pragmatic cluster randomized trial of 1596 high-risk patients, the program improved guideline-concordant care, including increased use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and newer therapies such as sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists. However, CKD progression was not reduced over the 17-month follow-up period.
The expanded Kidney-Care (K-Care) PHM program has enrolled approximately 3000 patients across 101 primary care practices, delivering more than 6600 e-consults, 5600 medication reviews, and 4700 patient education sessions over 3 years.
Clinical Implications
For managed care stakeholders, PHM offers a framework to shift CKD management toward earlier intervention and value-based care. Current programs have largely focused on end-stage kidney disease, where costs are highest, but the authors emphasize that targeting earlier CKD stages may delay progression and reduce downstream expenditures.
PHM models can standardize care pathways, improve medication use, and enhance access to specialty services, particularly for high-risk and underserved populations. Integration of social determinants of health screening, telehealth, and multidisciplinary care teams may further improve equity and patient engagement.
However, implementation challenges remain, including upfront investment in infrastructure, alignment with provider workflows, and the need for policy incentives to support value-based models. Additionally, balancing standardized care with individualized treatment remains essential to maintain patient-centered care.
The authors state that “a thoughtfully designed population health management approach…can modernize CKD care delivery and improve outcomes,” emphasizing that PHM strategies must align with health system priorities and incorporate multidisciplinary collaboration, data infrastructure, and patient-centered interventions.
Conclusion
PHM strategies leveraging electronic health records and coordinated care teams may improve CKD care delivery and support value-based health care goals. While early results show improved care processes, further research is needed to evaluate long-term clinical and economic outcomes and to address implementation barriers across health systems.
Reference
Jhamb M, Schell JO, Weltman MR, et al. Population health management for improving kidney health outcomes. AJKD. 2025;86(2): 263-271. doi:10.1053/j.ajkd.2025.01.020
