Chronic Kidney Disease (CKD) and Diabetes: Closing the Kidney Gap in Primary Care

Finding and treating chronic kidney disease (CKD) in your diabetes population is a quality, clinical and financial priority, and primary care can lead the way

November is National Diabetes Month, and most of the conversation will center around HbA1c, blood pressure, glucose control, tobacco use and weight management. Those matter. But one of the highest-impact opportunities in diabetes care is actually in the kidneys. For business and clinical leaders, it is also one of the clearest places where the goals of better clinical care and better financial performance can be delivered by the same program.

In October, ASN Kidney Week showcased a new generation of kidney therapies that can slow progression. This November, Diabetes Month, is where many of the patients who need them can be found.

 

The Scale of the Challenge: The Diabetes, CKD and Cardiovascular Triad

According to the Centers for Disease Control and Prevention (CDC), approximately 38 million Americans – more than 1 in 10 people – live with diabetes, while 37 million American adults have chronic kidney disease (CKD).

The overlap between these two populations is well known, and the risk for patients who have both diabetes and CKD is significant.

• Widespread Comorbidity: CDC surveillance data indicates that nearly 4 in 10 adults (38%) with diabetes also have CKD, making the prevalence of kidney disease more than three times higher in people with diabetes than in those without it. However, because early-stage kidney disease is overwhelmingly asymptomatic, most adults (87%) with CKD do not know they have it.
• The Leading Driver of Kidney Failure: Diabetes remains the single largest driver of end-stage kidney disease (ESKD) in the United States. Landmark studies of patients with both diabetes and CKD have shown that patients with both experience a 153% higher rate of progressing to ESKD than non-diabetic CKD patients.
• Compounded Cardiovascular Risk: Real-world studies of adults with both type 2 diabetes and CKD show a 99% increase in their risk of a major cardiovascular event (MACE) compared to patients with diabetes alone.

 

The KED Quality Measure: Exposing a Critical CKD Screening Gap

Even though we know that CKD is a comorbid condition in ~40% of patients with diabetes, and we know the implication of unmanaged CKD in those patients, according to NCQA reporting, fewer than 50% regularly get the recommended screening for kidney disease. Accurately detecting and staging CKD requires two tests: an estimated glomerular filtration rate (eGFR) blood test to assess filtration and a urine albumin-to-creatinine ratio (uACR) test to detect early kidney damage.

The National Kidney Foundation (NKF) and the National Committee for Quality Assurance (NCQA) introduced the Kidney Health Evaluation for Patients with Diabetes (KED) measure in 2020 to drive improvement in identifying kidney disease in diabetes patients. Now embedded across HEDIS, Medicare MIPS (Quality ID #488), and Medicare Advantage Star, KED tracks the percentage of adults aged 18–85 with diabetes who receive both an eGFR and a uACR annually.

Today, national KED performance is poor, averaging between 38% and 53% across commercial, Medicaid, and Medicare plans, meaning roughly half of all diabetes patients do not receive complete kidney screening each year. Yet history proves that health systems can dramatically improve performance when population health and quality programs are tied to payer incentives. For example, outcome composites like the Optimal Diabetes Care (D5) measure – still actively used today to track HbA1c, blood pressure, statin use, tobacco cessation, and antiplatelet therapy – helped drive annual HbA1c and eGFR blood testing compliance above 90%. In addition, NCQA officially retired the standalone “HbA1c Testing” process indicator in 2022, noting that national performance was “topped out” with little room for further improvement.

Applying that same intentional, programmatic focus to KED performance can rapidly close the uACR gap.

Why Closing the KED Gap Makes Business and Clinical Sense

Improving KED performance is both the right thing to do for patients and a compelling business imperative for health systems:

• Value-Based Revenue & Quality Scores: Closing KED gaps directly boosts HEDIS scores, Medicare Advantage Star Ratings, and MIPS reimbursement adjustments, unlocking pay-for-performance bonus payments.
• Bending the Cost Curve: CKD accounts for 25% of total Medicare spending (over $115 billion annually). Catching kidney disease early allows health systems to intervene early, delaying dialysis and avoiding catastrophic inpatient stays for acute cardiovascular events.
• Accurate Risk Adjustment: Under CMS-HCC V28, now fully phased in for 2026, the assignment of risk weights for CKD Hierarchical Condition Categories (HCC) has changed to put more focus on specific CKD diagnosis and staging. For health systems in total cost of care risk contracts, these changes increased the incentive to complete annual testing and specific documentation to ensure cost benchmarks accurately reflect the disease burden a health system is already managing.

 

The Therapeutic Revolution: SGLT2 Inhibitors and Guideline Consensus on CKD and Diabetes

Early disease identification matters most when there are safe and effective therapies available that are proven to improve patient outcomes. Sodium–glucose cotransporter-2 inhibitors (SGLT2i) are a prime example for patients with diabetes and CKD.

Originally developed to lower blood glucose, SGLT2 inhibitors have proven in multiple large clinical outcome trials to safely slow kidney disease progression and reduce the risk of MACE events in patients with diabetes and CKD. The authors estimated that for every 1,000 patients with CKD and type 2 diabetes treated for a year, there would be 11 fewer cases of kidney disease progression, 4 fewer episodes of acute kidney injury, and 11 fewer cardiovascular deaths or heart failure hospitalizations. In EMPA-KIDNEY, the largest dedicated CKD trial, empagliflozin reduced the composite of kidney disease progression or cardiovascular death by 28%.

The strength of this evidence has forged unprecedented consensus among leading clinical organizations:

• KDIGO Clinical Practice Guidelines: KDIGO issues a Level 1A recommendation, its highest possible endorsement, to treat adults with type 2 diabetes and CKD and an eGFR of 20 or higher with an SGLT2 inhibitor. KDIGO explicitly states that SGLT2i should be prescribed primarily for cardiorenal organ protection, even in patients whose HbA1c is already at target.
• American Diabetes Association (ADA) Standards of Care: In its Standards of Care in Diabetes, the ADA assigns a Grade A recommendation for annual uACR and eGFR screening in all patients with type 2 diabetes, alongside a Grade A recommendation to prescribe an SGLT2 inhibitor for qualifying patients with type 2 diabetes and CKD to reduce CKD progression and cardiovascular events.
• National Kidney Foundation (NKF): Through its national CKD Intercept initiative, the NKF strongly endorses dual eGFR and uACR testing in primary care paired with early initiation of SGLT2 inhibitors alongside renin-angiotensin system (RAS) blockade for qualifying patients.

Despite this level of support, broad access and relatively low cost, prescribing remains low. In a cohort of nearly 1.2 million adults with type 2 diabetes, only about 12% of those with CKD were prescribed an SGLT2 inhibitor. This poor compliance with guideline-directed therapy is impacting patient outcomes and health systems’ financial performance.

 

Empowering Primary Care: Building an Intentional System of Support

While primary care providers are best positioned to detect CKD in diabetes patients and initiate guideline-directed therapy, health system leaders must recognize that primary care cannot shoulder this burden alone. Primary care teams are already stretched thin by packed schedules, increasingly complex panels, and inbox overload. Expecting them to close KED gaps and keep pace with evolving prescribing guidelines through sheer willpower is a recipe for failure.

To succeed, health systems must surround primary care with an intentional, multidisciplinary ecosystem across four pillars:

1. Population Health Teams to Drive Outreach and Education

Population health teams must advocate for comprehensive goal-directed care models that are designed to meet established guidelines in alignment with the organization’s internal goals. By structuring care models with intentional features like patient and provider education, pre-visit planning, post-visit follow-up, clinical decision support, patient financial counseling and performance metrics that track progress, population health teams can provide support for primary care teams and help to drive significant improvement.

2. Finance and Managed Care Leaders to Align Incentives and Resources

Health system finance and contracting leaders play a pivotal role at the negotiating table. By working with clinical experts to model the cost benefit of improved quality performance, contracting teams are equipped to negotiate for larger quality bonus dollars tied to KED improvement in pay-for-performance contracts. Just as importantly, financial leaders must advocate for reinvesting a portion of quality bonuses and 340B pharmacy margins back into primary care to fund the clinical and operational support that is necessary to deliver sustained performance improvements.

3. Intelligent, Low-Friction Integrated Clinical Decision Support

Clinicians do not need more disruptive, low-value pop-up alerts; they need intelligent and relevant workflow integration directly inside the Electronic Health Record (EHR). High-performing health systems deploy clinical decision support (CDS) tools that:

• Provide easy-to-use disease management visit templates that automate recommended lab order sets whenever a diabetes visit is completed.
• Deliver context-aware medication therapy recommendations at the point of care, prompting the clinician to consider an SGLT2 inhibitor or other guideline-directed medication therapy for appropriate patients.
• Incorporate smart clinical suppression logic so the system automatically silences alerts when a patient has a documented contraindication for any recommendation, preventing alert fatigue and earning physician trust.

4. Clinical and Operational Leadership for Transparent Measurement

What gets measured gets improved. Clinical and operational leaders must partner together to design and deliver relevant, clinician-level and clinic-level performance dashboards. When care teams can clearly track their KED screening rates, CKD staging documentation, and guideline-directed therapy trends over time, clinical momentum builds rapidly.

 

Where to Start: A Pragmatic CKD Roadmap for Diabetes Month and Beyond

Transforming cardiorenal care across a health system does not require boiling the ocean on day one. The most effective organizations launch their programs with a phased, risk-stratified approach.

Health systems can analyze existing EHR data to prioritize outreach to the highest-risk patients first: those diabetes patients with indicators suggesting they may have undiagnosed CKD.

Closing testing and medication therapy gaps in the high-risk cohort of patients with both diabetes and CKD delivers immediate clinical value for patients, and immediate financial value for the health system. Once workflows, tools and care navigation pathways are proven in a pilot group, the system can scale to the entire diabetes population.

Improving quality measures and guideline-directed medication therapy can deliver financial benefit for the health system. But ultimately, the true measure of this strategy is best understood through the diabetes patient sitting in a primary care clinic today. Like nearly 9 in 10 adults living with CKD, they have no idea their kidneys are silently losing function. They come in faithfully for their diabetes management visits, get their blood drawn for an HbA1c, and leave believing their disease is being managed, unaware that undetected kidney damage is quietly multiplying their risk of a sudden heart attack, stroke, heart failure hospitalization, and moving them toward life-altering dialysis.

When a health system closes screening gaps, identifies comorbid CKD and connects the patient to guideline-directed therapy, they fundamentally rewrite that patient’s future: slashing their risk of major kidney failure outcomes by 38%, reducing their risk of a heart failure hospitalization by 36%, and lowering their risk of a major adverse cardiovascular event by 15%. For the patient, early detection and treatment can mean years of preserved health, independence, and time with family; for the health system, it represents one of the most impactful clinical and financial investments it can make this Diabetes Month.

 

Sources

• Chronic Kidney Disease in the United States, 2026 | CDC
• CKD Prevalence in Adults With and Without Diabetes | CDC Kidney Disease Surveillance System
• Preventing Diabetes Complications | National Diabetes Statistics Report | CDC
• Reported Cases of End-Stage Kidney Disease, United States, 2000–2019 | CDC MMWR
• Chronic Renal Insufficiency Cohort Study (CRIC): Overview and Summary of Selected Findings | Clin J Am Soc Nephrol, 2015
• Type 2 Diabetes and Chronic Kidney Disease as Long-Term Predictors of Cardiovascular Events in Patients with Coronary Artery Disease | Eur J Clin Invest, 2025
• Kidney Disease: Fact Sheet | National Kidney Foundation
• National Kidney Foundation FY24 Written Testimony
• Kidney Health Evaluation for Patients with Diabetes (KED) | NCQA State of Health Care Quality Report
• Kidney Health: A New HEDIS Measure | NCQA
• HEDIS 2022: See What’s New, What’s Changed and What’s Retired | NCQA
• 2025 SQRMS Technical Specifications – Minnesota Department of Health
• Closing the CKD Testing Gap: How the National Kidney Foundation Is Moving the Needle
• Fulfillment and Validity of the Kidney Health Evaluation Measure for People with Diabetes – PMC
• Quality ID #488: Kidney Health Evaluation | CMS
• Cognizant: Improving Kidney Health Evaluation with Da Vinci DEQM API
• Fact Sheet: 2024 Medicare Advantage and Part D Rate Announcement | CMS
• Impact of Diabetes on the Effects of SGLT2 Inhibitors on Kidney Outcomes: Collaborative Meta-Analysis of Large Placebo-Controlled Trials | The Lancet, 2022
• Effects of Sodium Glucose Cotransporter 2 Inhibitors by Diabetes Status and Level of Albuminuria: A Meta-Analysis | JAMA, 2025
• Empagliflozin in Patients with Chronic Kidney Disease (EMPA-KIDNEY) | NEJM
• Prescription Patterns of Cardiovascular- and Kidney-Protective Therapies | Diabetes Care
• KDIGO 2026 Clinical Practice Guideline for Diabetes and Chronic Kidney Disease (Public Review Draft)
• 11. Chronic Kidney Disease and Risk Management: Standards of Care in Diabetes—2025 | ADA