The University of Pennsylvania’s Leonard Davis Institute of Health Economics (LDI) has announced the first three grants awarded as part of its Research Initiative on Improving Management of Chronic Kidney Disease (CKD). The projects are designed advance the U.S. health care system’s capacity to effectively identify, manage, and improve the care received by CKD and end-stage kidney disease (ESKD) patients. They focus on making palliative care more easily and effectively available for stage 5 CKD patients; creating a virtual health assistant to increase patient understanding of the value of transplantation; and developing a system for better understanding the modality of end-state kidney disease care desired by patients and their families. The projects are:

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Promoting the Equity and Effectiveness of Home-Based Palliative Care for Patients With Dialysis-Dependent Chronic Kidney Disease

Principal Investigators: Scott Halpern, MD, PhD and Katherine Courtright, MD, PhD | Perelman School of Medicine

Despite experiencing morbidity and mortality that equal or exceed those in advanced cancer and heart failure, patients with advanced chronic kidney disease (stage 5) receiving hemodialysis (CKD5-D) have insufficient and inequitable access to palliative care (PC). In a recently completed pilot feasibility randomized trial among 200 patients with CKD5-D hospitalized at Penn Medicine, we found that nudging case managers to make referrals for home PC significantly increased home PC use, but most patients still did not receive this service. We identified actionable barriers to improved uptake, including that only 37% of patients lived in neighborhoods serviced by Penn Home PC, and that underserviced neighborhoods were lower income, more deprived, and home to more patients who identify as Black. These findings have motivated Penn Home Care to expand home PC services across its catchment area in March 2024. As the next step toward our long-term goal of ensuring that patients with CKD5-D have equitable access to effective PC services, we propose to (1) use qualitative and implementation science methods to optimize our intervention, (2) conduct a hybrid effectiveness-implementation trial among 400 patients to understand the intervention’s effectiveness in improving patient-centered outcomes and barriers and facilitators to its uptake and effectiveness, and (3) quantify how the refined intervention affects equity in access to PC before and after expanding the home PC service area. This first-ever pragmatic trial of home PC for patients with CKD5-D will generate evidence adaptable by all U.S. health systems to improve equity and outcomes for patients with CKD5-D.

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An Interactive, Conversational Virtual Health Care Agent to Educate and Engage Patients With Advanced Chronic Kidney Disease About Transplantation

Principal Investigator: Peter Reese, MD, PhD | Perelman School of Medicine

Over 35 million Americans endure the burdens of chronic kidney disease (CKD). Black Americans face particularly high rates of CKD due to environmental and genetic factors, including systemic racism and inadequate access to specialty providers and effective therapies. The optimal management of advanced CKD poses many challenges for patients, especially those with low health literacy, because of the complexity of medical management and treatment options. For many patients with advanced CKD, pursuing kidney transplantation has major advantages. Compared to chronic dialysis, kidney transplantation improves quality of life and length of life, and offers greater capacity to participate in important activities such as employment. Unfortunately, many patients do not gain sufficient information about kidney transplant or have misconceptions and fears about transplant. This knowledge gap exists in part because many patients have limited access to nephrology care and ineffective education during nephrology visits. New media technologies can address this need by enabling patients to interact with a virtual health care assistant that both empowers patients to direct the communication toward their own information needs and communicates with patients using language and norms that are comfortable. We will develop a virtual health care assistant to interact with, educate and counsel patients and their caregivers about kidney transplantation. The tool will provide content developed by the National Kidney Foundation, the leading patient-facing organization focused on kidney disease. Informed by patient partnerships, the tool will address in particular the needs and concerns of Black Americans with kidney disease.

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Evaluating the Impact of A Novel Kidney Care Pathway on Optimal Transitions for Patients with End-Stage Kidney Disease

Principal Investigator: Yuvaram Reddy, MBBS, MPH | Perelman School of Medicine

End-stage kidney disease (ESKD) is a common, debilitating, and expensive condition treated with dialysis, kidney transplantation, or conservative care. It affects 800,000 patients and costs Medicare over $50 billion. Unfortunately, care delivery for patients approaching ESKD is fragmented and inequitable, resulting in poor quality care. For example, only 36% and 27% of white and Black patients with chronic kidney disease receive pre-ESKD care from a nephrologist at least one year before the diagnosis of ESKD, suggesting that few patients—and even fewer marginalized patients—receive care that prepares them to choose their preferred modality of ESKD care. Improving optimal transitions to ESKD may lower mortality and reduce costs compared to “crash start” in-center hemodialysis. The goal of this study is to leverage data from Monogram Health and Humana to examine the effects and mechanisms of Monogram Health’s novel kidney care pathway on optimal transitions to ESKD, pre-ESKD care, health care utilization, and health inequities. Specifically, we will use coarsened exact matching to match two cohorts of patients—Monogram Health patients with chronic kidney disease and ESKD to similar Humana patients—following which we will use a difference-in-differences study design to evaluate clinical outcomes. This proposal leverages this initiative’s unique access to Monogram Health’s data to rigorously examine 1) mechanisms by which Monogram Health’s novel kidney care pathway can improve clinical outcomes for patients with kidney disease and 2) to what extent population-level kidney care pathways narrow inequities. These results will inform refinements to kidney care pathways that better address health inequities.