Could a VA Directive Overhaul Kidney Care?

Tejas P. Desai, MD


July 06, 2020

The Veterans Health Administration (VA) is a unique institution because it provides health insurance to those for whom it also provides medical care. As both an insurer and a healthcare deliverer, the VA is a vertically integrated division, which allows it to make widespread improvements in the way healthcare is delivered to our military heroes. One such improvement is outlined in VA Directive 1053: Chronic Kidney Disease (CKD) Prevention, Early Recognition, and Management.

The CKD Directive That Got 'Lost' in the Pandemic Noise

This is a relatively unheard-of directive, which is not reflective of its expected impact. The directive was published on March 17, 2020, and got lost in the COVID-19 pandemic and infodemic. It's worth our attention because it makes interesting changes to the way that CKD care is delivered to veterans and can serve as a model for private healthcare institutions. Veterans will now be screened for CKD through their primary care offices using a predefined order set and established definitions. The order set goes beyond the simple but often misinterpreted serum creatinine and will include urine albumin:creatinine ratios and age-adjusted eGFR calculations.

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Primary care offices will begin a CKD education program for those veterans identified as having CKD or being at substantial risk for CKD. Once an at-risk veteran is identified, nephrology specialty care can be expedited by using one of three telehealth options: a real-time videoconference with the primary care provider and the veteran from the primary care office at the time of the visit; a separate videoconference between the veteran and nephrologist; or an asynchronous e-consultation (aka, chart review) by the nephrologist. None of these options is meant to replace the in-person visit between veteran and nephrologist, but each decreases the delay for at-risk patients to receive specialty care.

Finally, after the initial primary care visit and the nephrology telehealth visit, both medical providers will create a CKD Care Plan. Available to the veteran via remote electronic health record access, the care plan will be updated by both the primary care physician and nephrologist at each significant medical transition point (eg, a surgical procedure, hospitalization, medication modification).

Could Directive 1053 Be a Model for Others?

Directive 1053 outlines a plan by which the three key stakeholders in a veteran's CKD care (the patient, the primary care physician, and the nephrologist) can educate about and expedite CKD care to the patient. By linking these three stakeholders through a living, breathing CKD Care Plan, education and communication should improve. Using telehealth modalities can expedite care not just at the initial presentation but repeatedly at various transition points if kidney function is in jeopardy or has declined. While it applies to VA facilities only, Directive 1053 may have a positive impact in CKD care for civilians, especially if this level of integration prevents the development of end-stage renal disease.

As a VA nephrologist, I am excited to participate in this directive, although it has not been fully implemented yet, probably because of the ongoing COVID-19 pandemic. Once it is up and running, many will be keenly observing the outcomes. What do you think of expanding this initiative beyond the VA? Share your thoughts in the comments below.

Tejas Desai is a practicing nephrologist in Charlotte, North Carolina. His academic interests include the use of social media for physician, student, and patient education. He is the founder of NOD Analytics, a free social media analytics group that serves the medical education community. He has two wonderful children and enjoys spending time with them and his wife.

Follow Tejas P. Desai, MD, on Twitter: @nephondemand

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