Capstone Project Assignment 3: Draft Mini Literature Review

Running head: CHRONIC KIDNEY DISEASE

1

Chronic Kidney Disease: Problems, Perceptions, and Strategies for Intervention

David Brown

Walden University

HLTH 4900, Section 2, Capstone

November 16, 2013

Instructor: Dr. Jody Early

CHRONIC KIDNEY DISEASE: PROBLEMS, PERCEPTIONS, AND STRATEGIES FOR INTERVENTION 2

Abstract

Chronic kidney disease is considered one of the most significant health issues affecting

morbidity and mortality and contributes heavily to the state of global health. Chronic kidney

disease (CKD) and end-stage renal disease (ESRD) are chronic illnesses that have a dramatic

impact on the cost of health care delivery in the United States. Early detection and intervention

are critical to the long-term prognosis of this patient population; however, a health disparity

exists because not everyone who is at risk for CKD has access to resources for screening and

treatment. One of the goals of community-level and national programs is to create parity of care

by focusing attention on marginalized communities that are at a statistically higher risk for CKD.

The global impact of CKD and ESRD is significant because long-term survival depends on

expensive technology and many regions of the world lack the resources needed to treat this

disease. Health behavior and culture are known contributors to the long-term survivability of the

disease. Since early detection is the key, creating screening programs that target populations at

greatest risk will have the highest impact, and be the most cost-effective solution to combating

this chronic illness.

CHRONIC KIDNEY DISEASE: PROBLEMS, PERCEPTIONS, AND STRATEGIES FOR INTERVENTION 3

Chronic Kidney Disease: Problems, Perceptions, and Strategies for Intervention

Chronic kidney disease (CKD) is considered one of the primary global health issues and

contributes significantly to the social burden of care. CKD, along with cardiovascular disease,

diabetes, chronic respiratory disease, and cancer, is a chronic illness that is classified as a non-

communicable disease (Healthy People 2020, 2013). Non-communicable diseases have a

significant societal impact to domestic growth, productivity, and health care costs and are the

most common cause of morbidity and premature death in the United States (Couser, Remuzzi,

Mendis, & Tonelli, 2011). Chronic illnesses are also characterized by physical and emotional

stressors that can become overwhelming when simultaneously coping with multiple

comorbidities (Moulton, 2008). Although the World Health Assembly has determined that non-

communicable diseases contribute heavily to the state of global health, they concede that public

health policy can dramatically affect patient morbidity and mortality (Couser et al., 2011). CKD

is a public health threat that is on the rise and will likely not slow without deliberate intervention.

This literature review will describe the impact that chronic kidney disease and end-stage renal

disease have on the global burden of care, as well as detail the issues that contribute to health

care disparities affecting this patient population. Factors that affect morbidity and mortality will

also be discussed and a solution will be presented that has the potential to reduce the health

system burden and improve the prognosis of many who suffer from this chronic disease.

Chronic Kidney Disease Statistics and Epidemiological Data

The impact of chronic kidney disease and end-stage renal disease (ESRD) on the federal

Medicare budget is staggering. In 2008, CKD cost $60 billion and ESRD totaled $39.5 billion,

which was 27% of the annual Medicare budget (Rettig, 2011). Recently, studies have reported

that approximately 26 million Americans have some degree of CKD (Navaneethan, Aloudat, &

CHRONIC KIDNEY DISEASE: PROBLEMS, PERCEPTIONS, AND STRATEGIES FOR INTERVENTION 4

Singh, 2008). Only 5% of the people in the most treatable early stages of CKD are aware they

have the disease, and almost 50% of those in stage 4 remain unaware unless diagnosed with a

comorbid condition such as hypertension or diabetes (Couser et al., 2011). As with many

illnesses, prevention and wellness programs that offer CKD screening can improve long-term

outcomes.

Prevention and Wellness Strategies for At-Risk Populations

Prevention and wellness strategies do much for mitigating the physiologic damage from

CKD, and can extend the productivity and mortality within this patient population. The greatest

benefits are realized when detection and intervention occur early in the disease cycle; however,

limiting factors such as genetic, environmental, and social barriers interfere with efforts to

deploy prevention and wellness strategies that can also screen for health issues (Pearson, 2008).

Although CKD is an illness that affects all cultural, geopolitical, and socioeconomic classes, not

all groups have the same clinical outcomes. Native Americans, Asian and Pacific Islanders, and

Hispanics have a greater likelihood of progressing to ESRD, and African Americans are four

times more likely than Caucasians to suffer renal failure requiring a kidney transplant (National

Medical Association, n.d.). The data indicates that a significant disparity exists between

Caucasians and other ethnic groups in the diagnosis and treatment of CKD. Evaluative and

preventative strategies are a part of high quality health care delivery, and involve interventions

that incorporate a diet plan, exercise routine, and medication protocol. Intervention strategies

should be tailored to the particular community since each of the disparate groups has ethnic and

cultural differences that must be factored to ensure interventional plan compliance.

The Impact of Quality Health Care Delivery on CKD

CHRONIC KIDNEY DISEASE: PROBLEMS, PERCEPTIONS, AND STRATEGIES FOR INTERVENTION 5

High quality health care delivery can have a dramatic impact on the morbidity and

mortality of people suffering from CKD. A study conducted by the National Kidney Foundation-

Kidney Disease Outcomes Quality Initiatives has proven that hospitalizations are reduced, and

mortality is improved if patients are referred to a nephrologist within one month of new onset

CKD (Navaneethan et al., 2008). This study also discovered that individuals were more likely to

be delayed in getting a referral if they were part of a minority, uninsured, less educated, or

elderly. Access to service, proper screening, and appropriate follow-through are challenges that

must be addressed if this disparity is to be eliminated. Evaluation and comprehensive counseling

on social and environmental factors that negatively impact health are important acute

interventions, and long-term health benefits are seen when early referral to a nephrologist and

access to follow-up care are provided (Collins, Gilbertson, Snyder, Chen, & Foley, 2010).

Currently, numerous programs exist that focus on high-risk populations and are designed to

provide access to screening and follow-up care. The National Kidney Foundation (2013)

sponsors KEEP Healthy, which is an extension of their Kidney Early Evaluation Program

(KEEP) and brings a nationally sponsored, community-based initiative designed to screen and

educate in regions that have statistically higher CKD populations. The Kidney Care Prevention

Program (KCPP) is a regional community-based program in North Carolina that staff trained

kidney care coordinators and educators who can intervene early in the disease process, and can

offer support through early-stage CKD intervention and management (Harward & Falk, 2008).

These are only two examples of community-based programs designed to provide individuals

with the best chance at early detection and intervention. Many such programs exist, and more are

being offered as federal funding becomes available.

The Global Impact of CKD

CHRONIC KIDNEY DISEASE: PROBLEMS, PERCEPTIONS, AND STRATEGIES FOR INTERVENTION 6

Although the impact of CKD on the United States and most developed countries is

significant, it is much worse in less developed countries. Screening programs are essential for

early detection, but many areas of the world lack the infrastructure to be able to offer these

services. Limited access to care and technology, poor living conditions and diet, and an

inadequate supply of pharmaceuticals results in rapid conversion from CKD to ESRD, which is

quickly followed by death (Couser et al., 2011). When CKD progresses to ESRD, the only cure

is a kidney transplant. Renal replacement therapy, which is also known as hemodialysis, can be

used as a bridge to transplant. There are 2 million people currently on hemodialysis worldwide,

which constitutes only 12% of the global CKD population, and nearly all of them are treated in

just five countries, including the United States, Japan, Germany, Brazil, and Italy (Couser et al.,

2011). This means that 88% of the world population does not have a bridge to transplant, nor do

they have access to renal transplantation surgery. When viewed from this perspective, it becomes

clear just how devastating a diagnosis of CKD can be to most of the world’s population.

Health Behavior and CKD

Health behavior plays a significant role in an individual’s ability to cope with and

manage chronic illness. Health behavior is so important in disease management that many health

behavior models have been created in an effort to understand the link. One of the oldest health

behavior theories is the Health Belief Model (HBM). The HBM asserts that people have an

inherent readiness to act, which is built from life experiences, self efficacy, the perception of

vulnerability to a given health problem, the severity of the issue, and the barriers and benefits to

taking positive action (Williams, Manias, Liew, Gock, & Gorelik, 2012). Life experiences fall in

the category of mediating factors, which also includes demographics, level of education,

structural, and social variables. It is theorized that mediating factors that greatly impact CKD are

CHRONIC KIDNEY DISEASE: PROBLEMS, PERCEPTIONS, AND STRATEGIES FOR INTERVENTION 7

primary causes of the current health disparity (Williams et al., 2012). Recognizing these

variables and creating practices that mitigate them are the keys to creating health parity across

the different CKD population groups. Culture can also affect health behavior and should be

considered when creating screening and intervention programs.

Culture and CKD

An individual’s culture influences their perspectives on health and wellness, which can

subsequently affect how well they manage their disease. One of the challenges with managing

patient populations that have a high incidence of undiagnosed and undertreated CKD is that they

tend to be culturally and linguistically diverse (CALD) groups (Williams et al., 2012). Chronic

disorders such as CKD, diabetes, and cardiovascular disease require a strict adherence to lifestyle

modification instructions and medication protocols. Limited health literacy, poor cognition, or a

language barrier inhibits effective communication and has been shown to result in poor health

outcomes (Norris & Nissenson, 2008). These communities are also at risk because they cannot

afford health care, have decreased access the health system, and have little or no access to

screening and testing facilities (Rettig, Norris, & Nissenson, 2008). These communities often

shun modern health services because historically conditioned biases have created in an inability

to trust or feel safe in contemporary health care delivery centers (Rettig et al., 2008).

Establishing community-based health clinics that are staffed and managed by lay health advisors,

especially in regions that have heavy racial and ethnic populations, will not only create

community buy-in, but also create agents of change. Lay health advisors are community

members who have a natural tendency to help, and are provided training and support so they can

assist and advise others in their community on various health issues (Pullen-Smith & Plescia,

2008). Overcoming health care disparities will require lay health advisors to be recruited from

CHRONIC KIDNEY DISEASE: PROBLEMS, PERCEPTIONS, AND STRATEGIES FOR INTERVENTION 8

within the affected patient population. Recruiting members from within the community has

resulted in improved attitudes as community members gain control over their own health issues.

The Role of Technology in Treating CKD

Patients with CKD and ESRD rely heavily on technology to manage their disease

process. Point-of-care testing that can measure creatinine, glucose, albumin, and other critical

blood values allows clinics to mobilize and bring much needed health care into the community

instead of waiting for members of at-risk groups to be proactive and seek screening centers

(Harward & Falk, 2008). The mobile centers have been instrumental in finding individuals who

are in the early stages of CKD and respond best to early intervention.

When CKD progresses to ESRD, the person must learn to embrace the technology that

will sustain his or her life until renal transplantation can be offered. Being tethered to a dialysis

machine several days a week for six hours at a time, constant testing, and living with a dialysis

catheter or fistula create a technological burden that can be overwhelming. Embracing

technology is not easy for patients to do because machine dependency runs contrary to the

freedom and autonomy that the individual previously enjoyed. Acculturation occurs when the

patient conforms to behavior patterns and routines that are needed in order to exist indefinitely

on machine dependency (Harward & Falk, 2008). At the point of acculturation, the patient fully

embraces the new technology and accepts it as an integral part of life.

Legal and Ethical Issues Impacting CKD

Besides technology concerns, there are many legal and ethical issues surrounding the

condition of CKD that can impact an individual’s ability to obtain the necessary treatment. In

October 1972, the federal government passed the Social Security Amendments, which extended

Medicare coverage to the disabled, and officially recognized ESRD as a disability (Vassalotti,

CHRONIC KIDNEY DISEASE: PROBLEMS, PERCEPTIONS, AND STRATEGIES FOR INTERVENTION 9

Gracz-Weinstein, Gannon, & Brown, 2006). In 2009, the American Recovery and Reinvestment

Act (ARRA) shifted the focus from reactive and therapeutic intervention, to a proactive and

preventative model (Menzin et al., 2011). Currently, instead of waiting and treating the terminal

disease of ESRD, which is ineffective, inefficient, and costly, clinicians are screening for CKD

in at-risk populations so that appropriate intervention can occur at a stage where the disease

process can be halted or even reversed.

There are other federal programs that help those suffering from CKD. A second example

of a public policy that focuses on active intervention is the Medicare Improvements for Patients

and Providers Act of 2008 (MIPPA), which provides funding to education programs for

individuals with stage 4 CKD (Menzin et al., 2011). The MIPPA has proven successful at

providing funding that creates highly effective targeted education.

The Interdisciplinary Team’s Approach to Treating CKD

The process of screening, treatment, and education need the involvement from many

disciplines within health care. An interdisciplinary team approach can be the best way to manage

complex illnesses such as CKD. Working within culturally and linguistically diverse

communities require teams that can provide a range of health care needs, facilitate

communication, and serve as patient advocates and representatives. Interdisciplinary teams

typically include physicians, technicians, linguists, social workers and case managers, and

community advocates, among others (Sinasac, 2012). These teams must also collaborate with

community agencies, which can enhance the effectiveness of health promotion efforts (Sinasac,

2012). Public health strategies can also include non-traditional groups such as community

service organizations, American Indian tribes, boys and girls clubs, and faith-based

organizations, which can penetrate deeper into the communities and reach individuals where they

CHRONIC KIDNEY DISEASE: PROBLEMS, PERCEPTIONS, AND STRATEGIES FOR INTERVENTION 10

live, work, play, eat, and pray (Pullen-Smith & Plescia, 2008). Interdisciplinary teams allow for

the breadth of services needed to make a significant impact on CKD screening and intervention.

The Scholar-Practitioner’s Role in Treating CKD

My role as a scholar-practitioner is to be aware of social disparities and endeavor to

correct observed societal imbalances. CKD is considered one of the most significant health care

disparities that exist in America today. As a scholar-practitioner, I must be a leader and advocate

for positive social change within my community. Becoming involved with organizations such as

the National Kidney Foundation’s KEEP Healthy program, the Minority Intervention and Kidney

Education (MIKE) program, or local organizations like the Kidney Care Prevention Program

(KCPP) are ways that I can influence social change as it relates to CKD and ESRD.

Opportunities exist for me to become a trained kidney care coordinator/educator and lead efforts

to promote health and wellness activities (Harward & Falk, 2008). Being a scholar-practitioner, I

can be involved with identifying a need and targeting the appropriate patient populations by

researching health status statistics and epidemiology studies, developing focus groups, assessing

social marketing strategies, and analyzing current evidence-based practices to be used in creating

new public health policies (Sinasac, 2012). As a scholar-practitioner, a worthy goal would be to

spearhead the formation of a new organization that brings health care services to minority

communities, socioeconomically depressed people, and the uninsured and underinsured. Another

way I can have an impact in my community and make a positive social change is to involve

myself with an existing organization whose goal is to eliminate racial and ethnic health

disparities for chronic illnesses such as CKD. Through these types of actions, I can fully embrace

the role of scholar-practitioner and become an agent of positive social change.

CHRONIC KIDNEY DISEASE: PROBLEMS, PERCEPTIONS, AND STRATEGIES FOR INTERVENTION 11

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