While the pipeline for cardio-renal therapeutics is expanding, clinical success still hinges on a silent variable: patient engagement. Roy O. Mathew, MD, associate professor of medicine at the Loma Linda VA Health Care System, discussed the inherent difficulty of treating “asymptomatic” risks and the challenge of finding the perfect integration of nephrology, cardiology, and primary care. The transition from small-scale multidisciplinary successes to national scalability remains a significant hurdle, he explained.
Mathew presented on kidney health as a determinant of cardiovascular risk during the 2025
Transcript was lightly edited.
Transcript
The American Journal of Managed Care® (AJMC®): What are the best practices for integrating care between nephrology, cardiology, and primary care to ensure seamless management of patients with coexisting kidney and cardiovascular risks?
Mathew: If I had the answer to that question, I’d be a millionaire, probably. I think we have had some models that have shown this, that there are ways to integrate care across clinics. We had the Cardiometabolic Center Alliance, which showed that you can really incorporate both cardiology and endocrinology into the management of patients with high-risk heart failure and diabetes in the chronic kidney disease space. Initially, it had been focused on chronic kidney disease, because it was such a diverse area of care. We’d bring in pharmacists, nutritionists, and social workers, along with the nephrologist. But I think that care has to now expand.
AJMC: How can different health systems adapt what works for what they have in place?
Mathew: Every health system is going to be a little bit different where the manpower is and who’s available in the areas. In rural areas, you’re probably not going to have as many specialists involved. There has to be a way to incorporate pharmacists, primary care, [and] extended care providers of nurse practitioners, physician assistants, and nursing care, and possibly even community care members.
Then, in the bigger health systems, there have to be ways of adjusting the payment systems, where you can figure out ways to get people together and to be able to provide patients with more patient-centered care. There’s a great system in University [Hospitals in Cleveland, Ohio]. The CINEMA [Center for Integrated and Novel Approaches in Vascular-Metabolic Disease] program is really focused on that, really bringing all the care providers to the patient. It’s a very patient-centric model.
The [AHA] CKM [Health] Initiative is really focusing on that, trying to find out what…are the models that work throughout the country, and that will be a good registry of information for people who want to try to implement that into their systems.
AJMC: What delivery models have proven most effective in improving patient outcomes and adherence to evidence-based guidelines for this patient population?
Mathew: I think the multidisciplinary care models have really shown that [they are effective]. The problem is they’re all really small studies—small-scale studies that have looked at single centers and a few patient populations here and there. We really need the larger trials of multiple health systems looking at multidisciplinary care versus usual care.
I think we really have to engage patients. There’s no way around it. We are getting more and more therapeutics involved. You have a patient who has decompensated heart failure; they’re feeling that. [In] some way, it’s a little bit easier to tell them you have to take all these medications. If you have a low eGFR [estimated glomerular filtration rate], albuminuria, some underlying cardiac disease, [or] elevated blood pressure, I almost guarantee you they’re not feeling any of those. If you have to tell them they need to take 4 medications when they were taking 2 or maybe none beforehand, that’s going to be very difficult. I think we need a lot of patient engagement.
We also need to incorporate community resources, and then also incorporate lifestyle [changes]. Something that I see in my clinics a lot is patients are always asking, “Doc, what about this herbal remedy?” Or “What about this natural remedy?” Or “I want to try lifestyle [changes].” Why didn’t you try it before? I think they want every opportunity to make themselves better. They know that the problem exists; we have to figure out how to better engage our patients. Once we engage them, I think eventually we can show them that these therapeutics work. But what that model is, I don’t have a good answer. I know that there are some data that show that the multidisciplinary care models work, and so that’s going to be helpful.
Now, in the future, generations are going to change, and I think that there’s going to be a generation that’s going to be more self-advocating and [have a greater] utilization of technology. How artificial intelligence is going to be involved, that’s still to be determined. There’s a lot of information out there. We have a lot of advertising on TV, on our smartphones, and how we can better use that in an intelligent way—I think that’s also going to be a next step for the next generation coming up.