Chronic kidney disease (CKD) is a major health problem worldwide due to its high prevalence, incidence, social and health burden, and growing economic costs.1 In Spain, the prevalence of CKD in any of its stages, has been estimated to be 14.4%2 to 15.1% for the general population,3 which could increase to more than 18% by the year 2040.4

CKD is associated with an increase in morbidity and mortality from the early stages of the disease, as well as with high frailty, increased hospitalizations, and reduced quality of life.3,5,6 It is also a risk multiplier for other chronic diseases (such as cardiovascular disease),1,7 and has been associated with high resource use and a considerable economic burden, which increases with disease progression8–10 and the presence of comorbidities.10 In the advanced stages of CKD, renal replacement therapy (RRT) accounts for between 2.5% and 3% of the National Health System (NHS) budget, even though it affects less than 1% of the population.11 Nevertheless, it continues to be an underdiagnosed disease12,13 that is largely unknown by society, probably due to the lack of symptoms that do not develop until the more advanced stages.14

CKD is generally included within the framework of chronic care models. In Spain, a specific framework document on CKD was developed in 2015 within the Strategy for Addressing Chronicity in the NHS,11 and Advanced Chronic Kidney Disease (ACKD)15 and Cardiorenal Units16 have been created and developed based on well defined standards as multidisciplinary and specialised functional models. In addition, in 2022, the Spanish information and consensus document for the detection and approach to CKD, signed by 10 scientific societies (SSs), was updated based on current recommendations and knowledge.5 It should be noted that the implementation of models, processes, programmes and units in CKD presents a high degree of heterogeneity among the different autonomous regions in Spain, possibly associated with differences in the organization of health care and the availability of resources.

In this context, the main objective of the intERCede project was to determine the care models for CKD patients at all stages of the disease and to reach consensus among a multidisciplinary panel of experts, on the key factors for an optimal model of care, defining a roadmap for the decision-makers and stakeholders involved in the management of this disease.

The consensus presented in this article has been endorsed by the following SSs: the Spanish Society of Nephrology (SEN), Spanish Society of Primary Care Physicians (SEMERGEN), Spanish Society of General and Family Physicians (SEMG), Spanish Society of Family and Community Medicine (semFYC), Spanish Society of Primary Care Managers (SEDAP), Spanish Society of Internal Medicine (SEMI), Spanish Society of Endocrinology and Nutrition (SEEN), Foundation Network of Diabetes Study Groups in Primary Health Care (redGDPS) and the Spanish Society of Health Managers (SEDISA).

This study utilises RAND Corporation and University of California, Los Angeles methodology with adapted Delphi (Delphi-RAND/UCLA) through two rounds of individual assessment carried out by a multidisciplinary panel of experts during which the appropriateness (first round) and necessity (second round) of the key factors identified for an optimal care model in CKD were assessed.

The methodology was developed in four working phases (Fig. 1).

Fig. 1.

Methodology followed to obtain consensus on challenges and key factors for an optimal model of care in CKD.

AC: advisory committee; CKD: chronic kidney disease; RAND/UCLA: Rand Corporation and University of California at Los Angeles.

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A multidisciplinary advisory committee (AC) was first established that included 15 professionals (Table 1) with extensive experience and knowledge in the field of CKD. An external methodological advisor also collaborated in coordinating and facilitating the project.

During the first two phases, CKD care in Spain was discussed and the care pathway of the CKD patient was analysed. This included a narrative review of the literature, as well as individual semi-structured interviews with the AC and a workshop. The result was, a preliminary proposal of the challenges and key factors for an optimal model of care in CKD, which was presented in the form of a structured questionnaire for evaluation in phase 3.

For assessment of these identified challenges and key factors, an additional multidisciplinary panel of 44 experts was formed (Table 1). Overall, the Delphi panel (AC and expert panel) was made up of 59 specialists representing different care models and geographical areas, all of them with experience and knowledge of CKD from their professional profile and field.

For the consensus and prioritisation of the key factors proposals, two rounds of assessment were carried out by means of a structured questionnaire via an online platform, using the RAND/UCLA consensus methodology17 (adapted Delphi) (Fig. 1, right side). These rounds were conducted in January and March 2023, respectively.

A 9-point Likert scale was used during the individual rating rounds to determine the appropriateness and necessity of the key factors. The response categories were described by linguistic qualifiers in three regions (1−3: inappropriate or unnecessary; 4−6: opinion neither for nor against, indeterminate; 7−9: appropriate or necessary). Experts were allowed to provide comments and observations in both rounds but were not permitted to exchange information; key factors not scored were analysed as missing cases for statistical purposes. The data obtained in the two rounds were analysed statistically (via Microsoft Excel) to measure the degree of appropriateness, necessity and concordance, using the following metrics: frequency, median, interquartile range, mean and standard deviation.

During the first round, the Delphi panel assessed the appropriateness of the preliminary proposal of challenges and determining factors. The application of the key element was considered appropriate when the health benefit expected from its use outweighed by a large margin the potential negative consequences or risks by a large margin. Each factor was analysed and classified according to the degree of appropriateness and concordance of the responses (Table 2). This was followed by a workshop with the AC to discuss specific key elements with indeterminate consensus, and elements with proposals for wording adjustments or with greater disparity.

In the second round, the panellists evaluated the need for the proposal of key factors adjusted after the consensus and assessment of the results obtained after the workshop. A key element was considered as necessary when it met the following four criteria: appropriate; it would be inappropriate or malpractice not to implement it; there is a reasonable possibility that it would benefit the patient; and the magnitude of the expected benefit is not small. Each was analysed and classified according to the degree of necessity and the concordance of the responses (Table 2). After this round, another workshop was held with the AC, in which the determining factors with indeterminate necessity were discussed, as well as those in which considerations had been presented.

Finally, the definitive list of challenges and key factors was obtained for an optimal model of care for patients with CKD. Those that obtained an average score of 8 or higher in terms of both appropriateness and necessity were considered as priorities. The results were included in a final report.

No patient data were collected in this project, so no review or approval by the ethics committees of the participating hospitals was required.

Based on the analysis of current patterns of care and the identification of the main patient pathways, the AC established a series of minimum characteristics for optimal models of CKD care: (1) prevention of the disease and periodic screening of patients with risk factors; (2) early diagnosis and appropriate recording thereof at all levels of care; (3) comprehensive and individualised follow-up; (4) proactive care, integration and coordination between areas, specialties and levels of care; (5) reinforcement of the training and awareness of patients and healthcare professionals throughout the entire care pathway; (6) evaluation of health outcomes and of the quality of life, experience and perspective of the person; (7) and development of information systems that facilitate the different stages of the care process.

Considering these characteristics, in addition to the analysis of the main areas for improvement and good care practices, the main challenges and key factors for progress in the development of optimal models of care in CKD were established.

In the first Delphi round, a total of seven challenges and 68 key factors were initially identified. Of these 68, 59 were rated as appropriate and with agreement, while nine received an indeterminate consensus. Following the deliberations of the AC during the workshop, and based on the clarifying considerations and observations for improvement made by the panellists, synergies between different key factors were identified, integrating them into those that were more precise and avoiding the dispersion of information (Appendix A Supplementary Fig. S1). None were eliminated. In addition, editorial changes were made to the initial proposal to ensure an accurate assessment aligned with a clear understanding. As a result, a final list of 38 key elements was obtained, structured into four challenges (Table 3), which were then subjected to a second round of assessment.

Challenge 1 arose from considering the poor visibility and prioritisation of CKD at all levels and in models and specific macro-, meso- and micro management tools. Challenges 2 and 3 arose from the description of the care pathway and the current room for improvement in terms of prevention, screening and early detection of CKD, as well as the need to ensure a comprehensive and individualised approach to the patient and coordination between the different professionals involved. Finally, challenge 4 arose from the need for training of healthcare professionals and also patients themselves and family members/caregivers, as key aspects necessary to optimise the health care model.

After the second round of assessment, of the 38 key factors, 35 were considered appropriate and clearly necessary, while three were considered appropriate but not clearly necessary. The final score and rating obtained for each of the key elements is detailed in Appendix Supplementary Table S1. In cases where the factor was the result of the integration of two or more factors, the appropriateness was calculated as the mean of the appropriateness score of the consolidated key aspects. The mean score of the challenges in terms of necessity was 8, with the exception of the second challenge, which scored the highest with a mean necessity score of 9.

As a final result, a total of 14 key factors were identified as high priority (Table 4). A matrix of prioritisation of all key elements based on on the mean appropriateness and necessity is shown in Appendix A Supplementary Figure S2. None of the factors in challenge 4 were considered as priority.

This study allowed us to identify various aspects to move towards optimal models of care in CKD with a high level of agreement and unanimity (Appendix Supplementary Table S1). We confirmed the existing consensus on the need to prioritise CKD both at social and health authority level, as well as the need to promote a paradigm shift towards prevention and an early approach. This will ensure comprehensive, multidisciplinary and coordinated follow-up throughout the disease process, together with training and raising awareness among professionals, patients and family members/caregivers. To date, and following a review of the scientific literature, this is the first study that identifies the challenges and key factors to advance in the development and implementation of optimal models of care in CKD at the national level.

The 38 recommendations or key factors proposed are intended to serve as a basis for advancing the development of optimal CKD models adapted throughout Spain, taking into account local models and available resources, thereby improving the quality of care.

The discussion is structured by challenges and focuses especially on these key priority factors, since these are the ones that mark the most immediate start of the roadmap. Once the essential elements have been implemented, the other basic elements identified should be incorporated progressively.

The results of this project show that there is consensus on the need to prioritise the care of CKD at both institutional and social levels, as well as to encourage a paradigm shift towards its prevention and early management, while guaranteeing comprehensive, multidisciplinary and coordinated monitoring throughout the disease process in addition to training and raising awareness among professionals, patients and family members/caregivers.

For the first time, this work provides a roadmap to move towards the definition of optimal models of care in CKD from a multidisciplinary perspective, through initiatives and actions that can potentially be implemented in the short term in the different health areas of Spain.

This Delphi intERCede project has been coordinated by Ascendo Sanidad&Farma, with the support and funding of Boehringer Ingelheim (BI) Spain. BI did not exert any type of influence on the opinions of the participating experts or the final consensus.

José Luis Górriz has received honoraria for lectures from AstraZeneca, Menarini, Boehringer-Ingelheim, Lillly, Bayer and Novo Nordisk. He has participated in advisory boards of Menarini, Boehringer-Ingelheim, AstraZeneca and Bayer.

Roberto Alcázar Arroyo has received f honoraria for continuing education activities from AstraZeneca, Boehringer-Ingelheim, Lilly, Bayer, Vifor-cls and Novo Nordisk. He has participated in advisory boards of Boehringer-Ingelheim, AstraZeneca and Bayer.

Patricia Arribas has received honoraria from Boehringer-Ingelheim.

Sara Artola has received honoraria for lectures from AstraZeneca, Menarini, MSD, Sanofi, Boehringer-Ingelheim, Lillly, Bayer, Almirall and Novo Nordisk. He has participated in advisory boards of Menarini, MSD, AstraZeneca and Alter.

Sergio Cinza-Sanjurjo has received honoraria for lectures from AstraZeneca, Boehringer-Ingelheim, Lillly and Bayer. He has participated in advisory boards of Boehringer-Ingelheim and Bayer. He has received research funding from AstraZeneca, Boehringer-Ingelheim, and Bayer.

Rafael de la Espriella has received honoraria for lectures from AstraZeneca, Boehringer-Ingelheim, Lillly, Bayer, Novartis, Pfizer, Daiichi Sankyo, and Novo Nordisk. He has served on advisory boards for Boehringer-Ingelheim, AstraZeneca, Pfizer, and Bayer.

Javier Escalada has received honoraria for lectures from AstraZeneca, Boehringer-Ingelheim, Esteve, Lillly, and Novo Nordisk. He has served on advisory boards for AstraZeneca, Boehringer-Ingelheim, Lilly, and Novo Nordisk.

Lisardo García-Matarín has received speaker fees from AstraZeneca, Boehringer-Ingelheim, Lilly, Chiesi, GlaxoSmithKline, Bial, Menarini, Teva, Novartis, Pfizer, Sanofi Aventis, FAES, Novo Nordisk, and Vifor Pharma. He has served on advisory boards from Boehringer-Ingelheim, AstraZeneca, Daiichi Sankyo, and GlaxoSmithKline.

Juan Carlos Julián declares that his entity, the National Federation of ALCER Associations, receives or has received in the last three years revenue in compensation for its participation in advisory boards for the companies Astellas Pharma Europe LTD, Astrazeneca, Bristol-Myers Squibb, Bayer Hispania, Boehringer-Ingelheim, Ipsen Pharma, GlaxoSmithKline, Hansa Biopharma AB, Novartis Inc., Novartis Farmacéutica, Pfizer Ltd., and Travere Therapeutics. The National Federation of ALCER Associations receives or has received in the last three years financial contributions for business collaborations within the framework of the Spanish Patronage Law, from the companies Astellas, Astrazeneca, Baxter, Bayer, Bristol-Myers Squibb, Bayer Hispania, Boehringer-Ingelheim, Chiesi, CSL Vifor, Deiters, Diaverum, Fresenius Medical Care, GlaxoSmithKline, Hansa Biopharma, Ipsen, Novartis, Pfizer and Sanofi.

José Pablo Miramontes González has received honoraria for lectures from Boehringer-Ingelheim, Lillly and Novo Nordisk. He has participated in advisory boards of Novo Nordisk.

Félix Rubial has received honoraria for lectures from Astellas, AstraZeneca, Boehringer-Ingelheim, Pfizer and Sandoz.

Mercedes Salgueira has received honoraria for speaking engagements and advisory board membership from AstraZeneca, Vifor, GlaxoSmithKline, Amgen and Boehringer-Ingelheim.

María José Soler has received honoraria for speaking engagements from AstraZeneca, Boehringer-Ingelheim, Lilly, Bayer, Vifor, ICU Medical, Fresenius, Travere Therapeutics y Novo Nordisk. She has participated in advisory boards of Novo Nordisk, Menarini, Boehringer-Ingelheim, AstraZeneca, Mundipharma, Vifor, ICU Medical, GE Healthcare, Travere Therapeutics y Bayer.

Jose Luis Trillo Mata has received honoraria for speaking engagements from AstraZeneca, Boehringer-Ingelheim, Lilly and Novo Nordisk. He has participated in advisory boards of Boehringer-Ingelheim, AstraZeneca and Bayer.