usual care.” They manage chronic conditions, such as the prevention and management of chronic kidney disease (CKD), using any medication that has been approved for the purpose. They may not specifically take into account the molecular medicine and the root causes of the condition.
Many of these patients are diabetic and hypertensive. Aggressive treatment of these conditions is needed to prevent the development and progression of kidney disease to end-stage renal disease requiring dialysis.
Related Content: A PCP Imperative: Integration of Behavioral and Physical Health Care
In addition, socioeconomic factors also play an important role. The cost of care can be a huge barrier to effective primary care access not only for the uninsured but also for the under-insured and those with high cost-sharing plans.
For people who can gain access to current primary care, treating hypertension and diabetes in usual care can be effective in preventing progression to dialysis. However, depending on which drugs are chosen to manage them, costs of care can vary widely.
Consequences of failure to prevent progression of CKD
Failure to prevent the progression of CKD poses significant health risks for patients. For example, one study found that “cardiac and vascular mortality are several times higher in dialysis patients than in the general population.”
Further, progression to dialysis is very expensive. The diabetic patient without CKD costs $10,721 annually. With stage 3 CKD and any progression, the cost is $31,693. The dialysis patient costs $62,091 a year.
Once a patient goes on dialysis, they automatically go on Medicare.
Even if you are miserly and hard-hearted…even if you care nothing for the plight of people less fortunate than you… you are going to pay for their much more expensive care down-stream.
It is in everyone’s hard financial interest to see that every American has access to cost-effective primary care, including critical generic medications.
Primary Care 2.0
As effective as Primary Care 1.0 is, it does not begin to realize the benefits that we could deliver with currently available best practice paradigms for chronic condition management. This is what takes place in Primary Care 2.0.
Using the prevention of CKD as an example again, we see that physicians aggressively and cost-effectively manage diabetes and hypertension using drugs that go beyond traditional risk factors.
They also follow guidelines that advocate focused, multifactorial interventions based on scientific evidence. And, they take cost into account by using generic drugs that target root causes. They also set aggressive clinical targets following their patients closely so they can tweak the interventions as needed.
The Steno-2 Trial
The Steno-2 trial is a great example of such an intervention. Participating physicians followed a protocol that combines ACE inhibitors for hypertension, statins for cholesterol, metformin for diabetes, and aspirin to prevent clots.
When applied, this approach has produced impressive results:
- six-fold reduction in dialysis compared with usual care
- four-fold reduction in heart attacks
- five-fold reduction in strokes
- eleven-fold reduction in coronary stents
- three-fold reduction in amputations
- three-fold reduction in dialysis
Optimal medical therapy
Luckily, optimal medical therapy can be systematized, industrialized, and scaled. There is no reason why patients cannot reliably receive this type of treatment regardless of whether they live in a big city or a small town.
Similar approaches could also (Note: this article is behind a paywall) be used to reduce the incidence of Alzheimer’s disease and other expensive chronic conditions in addition to dialysis. We believe that Primary Care 2.0 is a much more effective way to manage cardiometabolic diseases.
Primary Care 3.0
It is only with Primary Care 3.0 that we begin to see its full potential. There are thousands of people developing the new science of molecular medical management. However, few are working on translating the new science from bench to bedside.
This is unfortunat