# NIH grant: Enhancing PCP-Nephrologist Co-Management for CKD: Leveraging Population Health Management and Learning Health System for Scalable Solutions (1R01DK144089-01A1) — retained record

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[original source ↗](https://reporter.nih.gov/project-details/1R01DK144089-01A1)

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NIH grant 1R01DK144089-01A1: Enhancing PCP-Nephrologist Co-Management for CKD: Leveraging Population Health Management and Learning Health System for Scalable Solutions
Institute: {'code': 'DK', 'abbreviation': 'NIDDK', 'name': 'National Institute of Diabetes and Digestive and Kidney Diseases', 'admin_org_id': '12500020', 'admin_funding_url': ''}. PI: Manisha  Jhamb. Award: $753479.
Start: 2026-06-24T00:00:00.
Abstract
Chronic kidney disease (CKD) afflicts 37 million Americans and leads to increased morbidity, mortality, and
healthcare costs. With emerging CKD guidelines and highly effective new therapeutics, there is an urgent call
for scalable and resource-efficient population-level approaches to optimize CKD care. The overarching goal
of this proposal is to evaluate clinical- and cost-effectiveness of a multifaceted population health management
(PHM) implementation approach that facilitates PCP and nephrology co-management to deliver evidence-based
CKD care. Using a learning health system approach, we developed and implemented Kidney-Care, which is a
novel, electronic-health record (EHR) based, multi-faceted PHM intervention. It builds on successful elements
of our prior Kidney- Coordinated HeAlth Management Partnership (K-CHAMP) program, which included
centralized, remotely delivered intervention bundle with timely nephrology E-consults, pharmacist-led
medication management, nurse-led standardized patient education, and PCP academic detailing. In the
enhanced K-Care program, we targeted PCP’s therapeutic inertia and unfamiliarity with new guidelines through
reinforced academic detailing and experiential case-based learning through E-consults. We targeted patient
behavior change through education on CKD prioritization and importance of newer medications, hired a renal
social worker to address medication affordability and social risk factors, and expanded our team with a renal
dietitian and renal-palliative clinicians. K-Care program scaled up the intervention to 101 PCP practices within
our health system, providing access to ~ 24% rural-living patients. The proposed study provides a unique timely
opportunity to answer the following specific aims: 1) To compare the long-term clinical effectiveness of a
multifaceted CKD PHM intervention versus usual care on renal and cardiovascular (CV) outcomes among
patients with CKD at moderate-high risk of ESKD; 2) To evaluate effectiveness of CKD PHM intervention in
improving guideline-concordant care compared to usual care; 3) To assess the cost-effectiveness of CKD
PHM intervention compared to usual care. Using EHR data, we will conduct a target trial emulation to
determine the 5-year intent-to-treat effect of the K-Care program (n~3000) compared to contemporary usual
care using inverse probability of treatment weighted marginal structural models. Our primary composite
outcome is CKD progression (≥ 40% decline in eGFR or ESKD) or CV death. Secondary outcomes include
hospitalization for heart failure or CV death, hospitalization for any cause, death from any cause, CKD
progression, CV death, and major adverse CV events. We will also evaluate guideline-concordant care
outcomes (hypertension and glycemic control, albuminuria testing, medication use) and incremental cost
effectiveness ratio per quality-adjusted life-year gained. This proposal aligns with value-based CKD goals
outlined by Center for Medicare & Medicaid Services and the Advancing American Kidney Health Initiative.
```



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