Population Health Management for Improving Kidney Health Outcomes.

Chronic kidney disease (CKD) is globally prevalent, a leading cause of mortality, and is associated with poor patient outcomes and high health care costs. Gaps in guideline-concordant care are common across the continuum of CKD. These gaps lead to CKD progression, hospitalizations, and mortality and are potentiated by existing racial and socioeconomic disparities. A thoughtfully designed population health management approach that leverages electronic health records can modernize CKD care delivery and improve outcomes. Such an approach can potentially provide timely, equitable, resource- and cost-efficient care across health systems in a way that is scalable and data driven. Herein, we share our experiences with the implementation of nephrology population health initiatives at the University of Pittsburgh Medical Center across the CKD spectrum, which include ongoing and planned programs in the primary care, kidney-palliative care, kidney transplantation, and transitions of care settings. Further, we discuss the challenges of population health management and future directions that can move health care toward personalized medicine.