It is estimated that more than 1 in 7 adults in the United States has chronic kidney disease (CKD), a disease caused by diabetes, high blood pressure or other health conditions that causes severe damage to the kidneys, causing them to lose their ability to filter blood normally. Often called the “silent disease” and killing more people each year than breast or prostate cancer, chronic kidney disease is an underrecognized and underdiagnosed chronic condition. More than one-third of adults with advanced CKD don't even know they have the disease. A lack of early symptoms makes the disease difficult to identify before it reaches its later stages, and disparities in care and across the health care system have led to a critical lack of early intervention, especially among minority groups.
Women have a higher risk of kidney disease than men, in part because women have higher rates of autoimmune diseases such as lupus and arthritis, which can damage the kidneys. Certain complications related to pregnancy and childbirth, such as preeclampsia and gestational hypertension, also increase a woman's chance of developing chronic kidney disease. However, studies show that women are less likely to be diagnosed with CKD and referred to a nephrologist.
Disparities in kidney care are not limited to gender but also extend to race. African American patients with CKD require dialysis and kidney transplantation at higher rates than white patients. As a result, African Americans with chronic kidney disease face a higher risk of death. Minority groups are often underrepresented in clinical trials—on average, women make up 45% of CKD clinical trial participants, while African Americans make up only 9% of participants. Therefore, population health approaches to data mining and programming are even more important to prevent these disparities among patient groups.
Emphasis on preventive care within a value-based model
Early diagnosis plays a crucial role in preventing the progression of CKD. Within the value-based care (VBC) framework, strong emphasis is placed on patient education, routine monitoring of blood pressure and HbA1c levels, and strict compliance with prescribed medications. These proactive measures are critical to ensuring early recognition and management of CKD.
Access to care, often impacted by social or economic barriers, can significantly influence disease progression and lead to disparities in CKD treatment. Unlike traditional fee-for-service models, VBC providers provide resources designed to address these barriers, allowing all patients to have more equitable access to care.
For individuals whose CKD progresses to the point of requiring dialysis or transplantation, the VBC model prioritizes patient choices regarding treatment modalities, strategic planning for transplantation, and optimal initiation of dialysis. This personalized approach can support better health outcomes and align with patient preferences.
Additionally, the VBC model incentivizes equitable health outcomes through ongoing patient and population health monitoring. By identifying trends in specific populations and continuously tracking performance metrics such as preventive screening rates, patient satisfaction scores, and readmission rates, providers can pinpoint potential weaknesses in care interventions and services. This data-driven approach ensures continued improvement in CKD management and helps close gaps in care.
Coordinated, holistic care in a value-based model
The VBC model is designed to support individualized, holistic care of patients by addressing medical, behavioral, and social needs. This approach aims to achieve optimal health outcomes by considering the full range of factors that impact patient health.
Providers working within the VBC framework form multidisciplinary teams that collaborate throughout the continuum of care. These teams develop customized treatment plans to meet each patient's unique needs rather than relying on a blanket plan. This personalized approach takes into account the specific barriers some individuals may face, ensuring care is both effective and equitable.
A key component of the VBC model is the ability to aggregate disparate data sources. By integrating information on all aspects of a patient's health and condition, providers are able to identify and risk-stratify patient populations. This process helps prioritize patients in need of immediate care and identifies the types of interventions most likely to produce meaningful improvements in health outcomes.
Patients can enter the VBC system in a variety of ways: through self-referral, referral from a nephrologist or through identification through data analysis. Regardless of entry point, every patient begins with a comprehensive evaluation. The assessment includes screening for social determinants of health, such as income, housing, food security and the ability to receive appropriate care. These screenings ensure that all aspects of a patient's life that may affect their health are considered during the care planning process.
The VBC model brings significant benefits to CKD management by coordinating medical, behavioral, and social supports through a multidisciplinary team. This approach enables providers to personalize care, address barriers to access, and use data-driven strategies to identify and prioritize high-risk patients. Therefore, VBC not only improves outcomes and reduces disparities, but also ensures that each patient receives equitable, whole-person care.
Photo: HYWARDS, Getty Images
Heather Trafton is a respected industry leader with more than two decades of experience in the healthcare field and currently serves as CEO of Evergreen Nephrology. She began her career providing care to patients as a physician assistant (PA) and has spent the past decade working at high-growth, value-based healthcare technology companies, developing deep operational expertise in value-based care. As CEO, Heather leads Evergreen to improve patient outcomes while reducing the cost of care through sustainable and profitable renal value-based specialty care.
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