Population Health Management for Improving CKD Outcomes

PI(s): Manisha Jhamb, University of Pittsburgh

Project Summary: Chronic kidney disease (CKD) is associated with an unacceptably high human and financial cost. Over 12 million US adults have CKD stage 3-5. Primary care physicians (PCPs) deliver most care to patients with non-dialysis dependent CKD due to its growing prevalence and the relative dearth of nephrologists. However, PCPs report that limited CKD knowledge, time constraints, complex case-mix, and inadequate system-based resources contribute to gaps in CKD care. These shortcomings inevitably lead to increased CKD progression, hospitalizations, and mortality. By using electronic health record (EHR)-based information, population health management improves health by aggregating and analyzing data across a population to drive consistent, evidence-based care. This 5-year study will develop and validate prediction models using clinical electronic health record data to forecast economic and clinical outcomes to a meaningful time horizon.

Study Design: Risk prediction modeling will be used to develop and validate models to enhance PHM strategies

PaTH Partners:

  • Geisinger Health System (Les Kirchner, Site PI)
  • Temple University (Anuradha Paranjape, Site PI)

Sponsor: Industry

Coordinating Center: University of Pittsburgh

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