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One in seven American adults — 37 million people — have chronic kidney disease (CKD), an incurable condition with few treatments available to slow its progression or delay organ failure.

��(pictured), an associate professor and associate chief of the renal-electrolyte division in Pitt’s Department of Medicine, wants to make sure that the small number of existing treatments get to the right people — especially those in rural areas without access to nephrologists.

Her new five-year study will use real-world data to determine how an approach called population health management can close gaps in care delivery for CKD patients. A $5 million research collaboration with Bayer pharmaceuticals is making the work possible. ��

Population health management looks at members in a health system, such as UPMC where Jhamb is also a nephrologist, and builds algorithms to predict which patients might be at high risk for certain chronic diseases or poor outcomes, or which patients might qualify for a certain drug. It then alerts the patient’s primary care doctor (PCP) and suggests a referral to the appropriate specialist.

“It’s a very new way of doing things,” said Jhamb, adding that few academic medical centers in the country have health care delivery systems that can pull off testing this integrated approach to health care.

The PCP is usually a patient’s first stop for treatment of CKD, so it’s a logical moment to make sure patients are getting timely and up-to-date care. “We are providing resources to PCPs to inform care for these patients and help them implement the latest guidelines,” said Jhamb.

After the alert, the patient can opt for remote care delivery co-managed by a nephrologist and their PCP, alleviating the burden of having to physically see additional specialists.

“This way, we are working to engage patients earlier in the course of their illness, leading to improved outcomes,” said Jhamb. The approach can be particularly helpful for PCPs who are trying to manage a patient’s chronic kidney disease with few specialists nearby.

Jhamb and her team also offer an array of resources to patients who are at high risk for kidney disease and aren’t already getting nephrology care. The resources, which can be provided entirely remotely at no cost to the patient, include nephrologist recommendations, a medication review by a pharmacist and education from a nurse-educator.

“And it’s aligned with the PCP’s workflow, so it minimizes a lot of barriers at the PCP level and at the patient level,” Jhamb added.

Said Todd Williamson, vice president of data generation and observational studies at Bayer, about the novel process: “Understanding the impact that CKD progression has on patients, as well as the benefits of earlier identification and management, is important to document the potential benefits of a program like this in real world patient management.”

“There are not enough nephrologists to take care of everybody with chronic disease,” said Jhamb. “But we want to make sure we can come up with a strategy that is scalable, that is resource efficient, to empower PCPs. I think it’s just a huge win for everyone,” she said.

Jhamb was also recently named the director of Pitt’s new Center for Population Health Management, funded by the ���ϳԹ��� of ���ϳԹ���’s Department of Medicine, which is dedicated to applying this new health care delivery approach to other chronic diseases such as obesity and diabetes.

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— Micaela Corn, photo by Tom Altany