Shortly after his inauguration as New York's 54th Governor, on January 1, 2007, Governor Eliot Spitzer established the Chronic Kidney Disease Control and Prevention Task Force. As a result, New York joined a small but growing number of states that have undertaken initiatives to address chronic kidney disease (CKD). In a press release dated March 26, 2007, Lieutenant Governor David Paterson, speaking on behalf of Governor Spitzer, noted that the Task Force will be charged with developing a New York State strategic plan for CKD detection, control, and prevention. “Preventing kidney disease and its progression has the potential to improve quality of life for countless individuals and save millions of health care dollars by avoiding the need for dialysis and hospitalization.”
The development of state-based approaches to CKD is a relatively new phenomenon. The National Kidney Foundation (NKF) Kidney Disease Outcomes Quality Initiative (KDOQI) clinical practice guidelines on the evaluation, classification, and stratification of CKD, published 6 years ago,1 provided the scientific basis for new initiatives to identify Americans with CKD early in the course of their disease and facilitate appropriate interventions. In the same year that the Kidney Disease Outcomes Quality Initiative guidelines were published (2002), the Michigan Department of Community Health and the National Kidney Foundation of Michigan agreed to convene a task force to build a set of guidelines for reducing morbidity and mortality associated with CKD. The partnership resulted in a publication entitled “Reducing the Burden of Chronic Kidney Disease in Michigan: A Strategic Action Plan for the Prevention, Early Detection, and Control of Chronic Kidney Disease” in March 2005. An article published in the October 2005 issue of this journal, “A Public Health Action Plan is Needed for Chronic Kidney Disease,” highlighted the need for state and local initiatives along with national ones.2
Beginning in 2005, state legislatures began to enact laws to require estimated glomerular filtration rate (eGFR) calculation reporting whenever a serum creatinine test is ordered. Tennessee and New Jersey were the first states to pass such legislation. At least 11 states have developed some form of eGFR mandate. Eight states have required clinical laboratories to report eGFR: CT, GA, LA, MI, NJ, PA, TN, and VA. In the case of CT, the reporting is part of a requirement for an annual physical examination. In addition, in Georgia, Michigan, and Virginia, eGFR reporting is required for residents enrolled in the respective state's Medicaid program. eGFR legislation was introduced in additional state legislatures in 2006 but encountered opposition by physician groups, including the American Medical Association. In June 2006, the American Medical Association adopted Resolution 525, which had been introduced by the College of American Pathologists, opposing state eGFR legislation.
“Resolution 525 asks that our American Medical Association (1) support the position that the eGFR calculation, when appropriate and feasible, is a clinically useful calculation that should be promoted in the medical community in a scientific manner as a calculation that does NOT require state legislation or state law that would create an inflexible, politically-based mandate for the practice of medicine that, in general, can be deleterious to patient care; and (2) policy is that legislation mandating the eGFR calculation improperly and detrimentally prescribes medical decision-making to the extent that it deprives a physician of the ability to make appropriate, patient-specific clinical judgments regarding the performance of the calculation.”
During 2006, the number of states with CKD task forces multiplied as an alternative to legislation that mandates eGFR reporting. The NKF Board of Directors took the position that a state CKD task force would provide a more comprehensive approach to the epidemic of CKD in this country (National Kidney Foundation, personal communication, April 2006). This is because the state CKD task force movement envisions public, patient, and professional education campaigns as well as policy change to meet the challenge of the CKD epidemic. In addition, NKF research indicates that the examination of the albumin:creatinine ratio detects CKD in individuals who may not be characterized with CKD based on eGFR. In January 2007, the NKF and the College of American Pathologists issued a joint statement that urges state legislatures not to consider legislation mandating performance of eGFR calculations and take up legislation to establish CKD task forces at the state level instead. The statement characterizes the task force as a preferable form of enactment.
The mission of these state CKD task forces is to bring together all stakeholders to consider opportunities for early identification and intervention within the context of local needs and resources. In 2006, the respective state legislatures called for CKD task forces in the following states: Alabama, Mississippi, North Carolina, and South Carolina. During the following year, 4 more state CKD task forces were added in Massachusetts, Missouri, New York, and Texas. In most cases, the state task force has resulted from legislation. As noted earlier, however, in New York, Governor Spitzer created a task force without action by the Assembly or the Senate. The legislated task forces typically require the body to compile its findings and recommendations and file a report with the legislature within a specified time frame. After filing this report, the task force is to be disbanded. (This is known as a “sunset” clause.) Often a representative of an NKF affiliate or division is designated as a member of the Task Force. In a few cases, the local NKF staff members have assumed even greater responsibility for the operation of the task forces.
Model legislation developed by NKF staff suggests the following composition for a state CKD task force: (1) 2 members of (each house of the state legislature) appointed by the (respective leader of each house); (2) 2 physicians appointed from lists submitted by the (state medical society); (3) 2 nephrologists; (4) 2 primary care physicians, including a family physician; (5) 2 pathologists; (6) 1 member who represents owners/operators of clinical laboratories in the state; (7) 1 member who represents a private renal care provider; (8) 2 members who have CKD; (9) 1 pharmacist; (10) 1 member who represents the state affiliate of the NKF; and (11) additional members may be chosen to represent public health clinics, community health centers, and private health insurers.
The NKF suggests that the task force include both representatives from the state legislature and the state health department because each branch of government may be involved in implementing the recommendations that the task force proposes. Each task force has developed a unique approach to fulfilling its responsibilities. Some have held 2 or 3 meetings that culminated in a final report. On the other hand, the North Carolina CKD Task Force has convened almost monthly. The New York State CKD Task Force will be sponsoring a series of public forums around the state to solicit community input for its recommendations. Most state task forces have limited the scope of their activities to recommending new or expanded programs. However, some task forces have themselves delved into programmatic activities.
The “first priorities” identified by the South Carolina CKD Task Force included education programs targeted to primary care physicians serving high-risk populations as well as targeted CKD screening initiatives. The South Carolina Task Force also recommended that the state establish a CKD Governing Board to oversee the funding and implementation of the programs it recommended after the Task Force disbanded. (The membership of the CKD Governing Board would mirror that of the CKD Task Force.) The Alabama CKD Task Force explored possibilities for including CKD in the various ongoing programs of the state health department, such as “Steps to a Healthier Alabama,” the Cardiovascular Health Branch, and the Diabetes Branch.3 The Mississippi CKD Task Force arranged to have eGFR “slide rules” mailed to practitioners and clinical laboratory directors throughout the state.
There are a variety of other state initiatives that do not follow either of the 2 models discussed previously. For example, in 2005, the Indiana legislature added kidney disease to the indications, which include diabetes and hypertension, for which Medicaid-managed care programs must develop disease-management plans. The following year, the House-enrolled Act No. 1242 required Indiana Medicaid disease-management programs for diabetes and hypertension to have a kidney component. “The disease management program services for a recipient diagnosed with diabetes or hypertension must include education for the recipient on kidney disease and the benefits of having evaluations and treatment for chronic kidney disease according to accepted practice guidelines.” In 2007, West Virginia Governor Manchin signed Senate Bill 18 (Chapter 133, Acts, Regular Session, 2007), which requires the Public Employees Insurance Agency and Medicaid to cover testing for CKD and to provide outreach by the Bureau for Public Health to providers regarding CKD. The Florida Renal Coalition has developed a CKD/End-Stage Renal Disease Advisory Committee that will meet with the Florida Agency for Health Care Administration (the state Medicaid agency) and elected officials to provide advice, guidance, and recommendations to improve the CKD/end-stage renal disease program in Florida.
It might be premature to evaluate the impact of these state CKD initiatives. On the other hand, some positive developments may be worth mentioning. According to the National Kidney Foundation of Michigan, an increase in the percentage of Michigan laboratories reporting eGFR can be attributed to the discussion of eGFR reporting during the meetings of the state CKD task force, the identification of advocates for eGFR reporting in the state's laboratory community by the task force, and task force–recommended educational programs for laboratory personnel. As a result, the percentage of Michigan laboratories reporting eGFR increased from 40% to 70%. Based on recommendations from the South Carolina CKD Task Force, the state legislature appropriated $200,000 to support professional education and screening programs under the auspices of the NKF of South Carolina. In New Jersey, 53% of laboratories that perform serum creatinine testing were reporting eGFR values by January 2006, and an additional 30% were reporting eGFR by April 2006. By July 2006, 8 months after the effective date of the legislation, all New Jersey laboratories had initiated eGFR reporting.4
Several local kidney foundations that are NKF affiliates or divisions will be advocating state CKD Task Force legislation during the 2008 legislative sessions in their respective state capitals. Women in Government, a national organization of women state legislators that provides leadership opportunities, networking, expert forums, and educational resources to address and resolve complex public policy issues, has developed a toolkit on CKD legislation.
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