Cardiovascular-Kidney-Metabolic Conditions and Population Health: The Need for an Integrated Care Strategy.

Cardio-kidney-metabolic (CKM) syndrome, characterized by the combination of metabolic factors (obesity, diabetes), chronic kidney disease (CKD) or cardiovascular disease (CVD), is highly prevalent and confers a high risk of morbidity and mortality. The treatment of CKM syndrome is rapidly evolving, with multiple treatments now shown to reduce CKD progression, and incident CVD and heart failure - creating a unique opportunity to alter the natural history of CKM syndrome and improve population health. While efforts to improve the treatment for CKM syndrome have principally focused on clinician-level interventions, such as reminders or education, these strategies have had only a modest impact on population health. In contrast to clinician-level interventions, integrated care programs are collaborative healthcare teams and/or organizations delivering comprehensive person-centred care by removing barriers, supporting people throughout their healthcare journey and increasing healthcare capacity and equity. In randomized controlled trials, integrated care programs have demonstrated efficacy in increasing the use of guideline-directed treatment for people with CKM syndrome. This paper will review the evidence supporting integrated care programs as a population health strategy for CKM syndrome and propose a framework for integrated care programs specific to CKM syndrome to deliver the quadruple aim of better patient experience, improved population health, reduced healthcare costs and improved provider well-being.