Population Health Management Programs in CKD: Promise and Pitfalls

A new qualitative analysis from the OPTIMIZE-CKD study, published in Kidney Medicine, highlighted both strong support for comanagement between primary care providers (PCPs) and nephrologists and persistent gaps in patient understanding of chronic kidney disease (CKD) progression and management.1

The study explored patient perspectives on the Kidney Coordinated HeAlth Management Partnership (Kidney-CHAMP; NCT03832595), a population health management (PHM) intervention designed to optimize care for patients with chronic kidney disease managed in primary care.

Education sessions by nurse educators were widely well-received, especially when they helped patients manage anxiety and provided actionable guidance. | Image Credit: Minerva Studio - stock.adobe.com

CKD affects about 14% of US adults over age 30, yet most patients with nondialysis-dependent disease are managed by primary care providers who may lack the specialized training, time, or resources for optimal care.2,3 These gaps can accelerate CKD progression and lead to complications such as unplanned dialysis starts, highlighting the need for innovative, multifaceted approaches like PHM.1

This ancillary study conducted semi-structured interviews with 45 patients randomized from the Kidney-CHAMP intervention group, stratifying by racial/ethnic minorities, low socioeconomic status, and multimorbidity from May 2021 to February 2022. Participants had a mean age of 75 years, 44% were women, 9% were non-White, 59% had low socioeconomic status, and 77% had a Charlson comorbidity index ≥8. Hypertension was universal (100%), while 73% had diabetes and 91% had cardiovascular disease. The mean eGFR among participants was 38 mL/min/1.72 m² (range, 19-61). All participants attended at least one nurse-led CKD education session, delivered via telemedicine.

The Kidney-CHAMP intervention combined 3 elements: nephrology e-consults for PCPs, pharmacist-led medication reconciliation, and standardized nurse-delivered CKD education sessions using National Kidney Foundation and CDC materials. The study revealed broad patient support for collaborative CKD comanagement. Many valued nephrology input, citing specialist expertise. Others, however, noted frustration with duplicative office visits.

Education sessions through Kidney-CHAMP yielded variable effects on patient understanding, the study reported, “Although all patients had received standard CKD education, patients had varied levels of understanding about the role of kidneys and what CKD meant.” There was a notable lack of awareness regarding the health impacts of CKD, including recognizing cardiovascular complications and incorrectly attributing back pain or urinary frequency to CKD. Many did not associate cardiovascular disease risk with CKD, only being aware that it can result in needing dialysis or kidney transplant.

Patients’ self-management strategies were often limited to broad concepts such as reducing sodium intake and drinking more water. Avoidance of nephrotoxic medications was inconsistently recalled, though some did report counseling to discontinue NSAIDs. Patients who internalized the implications of CKD, such as progression to dialysis, expressed greater willingness to engage in lifestyle modification.

Education sessions by nurse educators were widely well-received, especially when they helped patients manage anxiety and provided actionable guidance. While two-thirds of participants described the education as helpful, patients consistently requested more frequent and personalized sessions. One participant explained, “It wasn’t individualized enough… what I should be practicing or doing to try to prevent dialysis.” Others highlighted the need for simple language, written materials, and concrete action plans: “…a list of things that you can do to improve, like, these are definite things that you have to do…like a shopping list.”

The study’s limitations included low representation of non-White individuals, recall bias, difficulty separating pre-existing knowledge from education gained during the intervention, and the absence of validated measures for health literacy, patient knowledge, and activation.

Despite the benefits of Kidney-CHAMP, the study revealed important shortcomings in patient education. Many patients continued to demonstrate limited or inaccurate understanding of CKD, with nearly one-third unable to explain the disease or its implications despite standardized nurse education. The authors note, “more effective approaches to communicating risk of CKD development and progression are needed.” Future recommendations include organizing CKD education into a series to reinforce key take-home points, diversify lessons, and enable participants to problem-solve and share experiences with other people living with CKD.

References

1. Lavenburg LU, Devaraj SM, Gul A, et al. Patient perceptions of a population health management program to improve kidney care: optimizing care in CKD. Kidney Med. 2025;7(7):101025. doi:10.1016/j.xkme.2025.101025

2. Centers for Disease Control and Prevention (CDC). Chronic kidney disease in the United States, Centers for Disease Control and Prevention. 2024. Accessed August 19, 2025. https://www.cdc.gov/kidney-disease/php/data-research/index.html

3. Abdel-Kader K, Greer RC, Boulware LE, Unruh ML. Primary care physicians' familiarity, beliefs, and perceived barriers to practice guidelines in non-diabetic CKD: a survey study. BMC Nephrol. 2014;15:64. doi:10.1186/1471-2369-15-64