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In August, the Centers for Medicare and Medicaid Services (CMS) began their Chronic Kidney Disease Project across the U.S. to address the burden of the disease on the healthcare system. Chronic kidney disease (CKD) affects 11 percent of the U.S. population over age 65. CKD is the ninth leading cause of death in the U.S. and the healthcare costs to Medicare are vast. Having diabetes is the greatest risk factor for CKD, but the correct management of diabetes and the detection of early kidney disease can help reduce the incidence of CKD.

Tennessee was selected as one of 10 states in the project to adopt interventions for detecting and decreasing the progression of CKD. The initiative is also designed to foster collaborations for system change at the state and local level, which include public reporting of data. QSource, Tennessee's Medicare Quality Improvement Organizations (QIO) will be implementing the statewide project and data collection. The initiative will focus on counties with the greatest need: Shelby, Davidson, Knoxville and Hamilton.

Tennessee ranks 14th in the nation in the number of Medicare beneficiaries with diabetes. According to the Tennessee Department of Health, diabetes is the sixth leading cause of death overall in the state and the third leading cause of death for African-Americans.

"With those four counties, we're reaching 27 percent of the diabetic population in Tennessee," explained Stacy Dorris, CKD manager for West Tennessee. "We're essentially targeting the diabetics to slow the progression of CKD."

Medicare data reveals there are approximately 132,000 beneficiaries with diabetes in Tennessee. The county with the largest number of diabetics is Shelby (14,000+), followed by Davidson (8,000+) and Knox and Hamilton counties (each have 7,000).

The four clinical areas addressed in the project include diabetes mellitus, preventive care, early stage renal failure, and CKD. Project coordinators are targeting primary care physicians, endocrinologists, nephrologists and other specialists providing care to Medicare beneficiaries. By signing up, physicians agree to let QSource come on site and provide technical assistance to evaluate their current diabetic patient workflow process and adopt quality interventions, as well as provide patient education materials.

"The providers we're targeting are those who treat a high volume of specifically Medicare beneficiaries, but the quality interventions we implement at the practice level will not only help the Medicare patients but also all diabetic patients," Dorris explained.

According to QSource data, early manifestation of CKD in individuals with diabetes is often under-diagnosed due to the absence of an annual urine microalbumin screening to identify kidney damage. Early kidney disease has no symptoms, and left unchecked, early kidney disease can lead to kidney failure. According to the United States Renal Data System, the savings to Medicare for each patient who does not progress to dialysis is estimated to be $250,000 per patient.

In order to meet project goals, various quality measures will be implemented. The first goal, detection, requires involved PCPs and endocrinologists testing their diabetic patients with annual urinary microalbumin screening. The next goal, slowing the progression of CKD, may be achieved by increasing the frequency with which diabetics and patients with early stage CKD (stage 1 to 4) are treated with an ACE inhibitor and/or ARB agent if diagnosed with hypertension.

"The only way that we will be able to effectively prevent chronic kidney disease is by moving our efforts out into primary care," commented Daniel E. Brewer, MD, a urologist with University Family Physicians in Knoxville.

For patients who are in kidney failure and have elected hemodialysis as their treatment option, the third goal of the CKD project is to ensure that Medicare patients receive comprehensive renal placement therapy. The project holds arteriovenous fistula (AVF) placement and maturation as a first choice for AV access where medically appropriate. Project coordinators contend that proper renal therapy counseling will allow for sufficient time to discuss AV fistula, and call it the "gold standard" for obtaining vascular access for dialysis. Nephrologists and vascular surgeons will be targeted for this measure.

To address the fact that minority populations are more likely to develop CKD, QSource will incorporate improving disparities into all aspects of the CKD project and will intensify efforts in Shelby and Davidson counties to improve early referral to a nephrologist and AVF placements with underserved populations.

"As a kidney specialist, I see the result of what happens when patients have long-standing diabetes and hypertension. Often times, it leads to complete kidney failure and dialysis," said R. Brad Canada, MD, interim chief of the University of Tennessee Health Science Center Division of Nephrology. "QSource's project on kidney disease is aimed at detecting early signs of kidney disease in diabetic patients. We need to detect it early to slow the loss of kidney function. We hope the QSource project will increase testing and treatment by increasing awareness, not only by physicians, but also by patients with diabetes so they can request screening."

As the healthcare industry evolves in the information age, and quality benchmarks progress, the importance communication between doctors on what works and what doesn't, is essential to improving preventive care and disease treatments. The project's final goal: collaboration.

Doctors who choose to volunteer for the project can also opt to be part of QSource's Physician Quality Reporting Initiative (PQRI), a CMS initiative to motivate physicians to participate in reporting data on quality. Starting in 2009, if physicians submit billing codes for the four measure groups via their claims, they can receive up to 2 percent of their total Medicare billing for all diagnoses that year. An additional 2 percent can be earned for those who choose to implement e-prescribing.

QSource will help physician offices utilizing health information technology (HIT) to identify where parts of their system can be implemented for these measures. However, Dorris maintained, if the office is fully paper-based, they can still benefit from this project.

"Our rationale is, if you're working with us, you're submitting and collecting this data anyway," said Dorris, "so why not go ahead and send it and have some incentive for doing the right thing?"

Some physicians may be reluctant to volunteer for the quality initiative for fear that it may cause extra work, but Dorris assured that is not the case.

"By us coming on site and providing that free technical assistance, we're helping them look at their diabetic patient processes and use them more effectively and more efficiently," she said. "It (ensures) patients receive the right care every time they're in the office, and it takes the burden off staff trying to remember every (test)."

"Diabetes is a costly disease for both a patient and the healthcare system," said Richard Carroll, practice administrator, Cookeville Medical Center. "That's why we decided to partner with QSource to slow the progression of chronic kidney disease. Thanks to their free technical assistance, expert QI specialist and free tools and resources, we are able to better educate staff and patients about the disease and truly make a difference in halting this disease."

Ultimately, QSource officials acknowledge the reporting portion of this project is a stepping stone toward a pay-for-performance system.

"We're asking everyone to get on board now, get involved and get behind (public reporting) because we want to be ahead of the eight-ball instead of behind the eight-ball on reporting quality," maintained Roberta Esmond, community QI specialist for QSource.

By becoming involved with PQRI now, added Esmond, "systems will (already) be in place and you're giving Medicare beneficiaries quality care."

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