NCQA Releases New White Paper on Improving Quality of Care for Patients with CKM Syndrome

February 4, 2026 · Becky Kolinski

Cardiovascular-kidney-metabolic (CKM) syndrome is a convergence of three interconnected chronic conditions: cardiovascular disease, chronic kidney disease and metabolic disorders, such as diabetes and obesity. Together, these conditions affect hundreds of millions of Americans, causing considerable morbidity, mortality and healthcare resource utilization.

“The growing prevalence of CKM syndrome and its widespread impact on population health signals the need for a unified framework that integrates prevention, treatment and quality measurement,” says Adrianna Nava, PhD, RN, NCQA’s Applied Research Scientist. “NCQA sees an opportunity to transform CKM care from fragmented, disease-specific management to holistic, patient-centered approaches.”

Our Approach to Evaluating CKM Care

In 2025, NCQA convened three meetings to address the challenges associated with CKM syndrome. The first meeting focused on ways to improve the quality of care for people with chronic kidney disease. The Advancing Care for Chronic Kidney Disease: Using Care Gaps to Inform a Quality Framework white paper captures the dynamic discussions and insights from this convening.

The second and third meetings reconvened the roundtable participants to discuss ways to improve the quality of care for CKM syndrome. The new white paper, Cardiovascular-Kidney-Metabolic Syndrome: Improving Quality of Care and Accountability, captures insights from these convenings.

The white paper outlines a comprehensive approach to improving the quality of CKM care and accountability. It explores five key domains essential for transforming CKM care.

1. Defining ideal care, identifying feasible CKM measures and breaking down silos.
2. Clinical integration, risk stratification and life course perspectives.
3. Patient and community engagement.
4. Technology as a driver of CKM syndrome.
5. Payment reform, health plan and health system coordination.

NCQA gathered input from experts representing a wide variety of disciplines: primary care, pediatrics, nephrology, cardiology, endocrinology, internal medicine, epidemiology, pharmacy, geriatrics, nutrition, gastroenterology, lifestyle medicine, nursing, hepatology, diabetes education, informatics and health policy. The convenings also included three patient advocates who provided valuable input based on their personal experiences with severe kidney disease and diabetes.

Key Findings and Recommendations

This report proposes a framework for improving CKM care quality through measurement and accountability. Recommendations include:

• Measure Integration and Alignment. Reduce the emphasis on process-oriented metrics and develop and promote intermediate outcomes like BP, HbA1c and uACR that are aligned with CKM risk stages and can be tracked over time.
• Risk-Based Framework. Use evidence-based tools and risk calculators to guide early detection, prevention and precision management.
• Cross-Specialty Accountability. Embed CKM coordinators, shared care plans and multidisciplinary documentation to align specialties around shared outcomes.
• Patient-Reported Outcome Measure (PROM) Integration. Incorporate PROMs assessing self-efficacy, health outcome goals, treatment burden and quality of life into performance frameworks.
• Technology Modernization. Invest in interoperability, predictive analytics, remote monitoring and automation to support proactive care.
• Social Determinants of Health Focus. Integrate social needs screening, referral tracking and community partnerships to close disparities.
• Value-Based Payment. Link reimbursement to intermediate outcomes and progression metrics that reward health plans and systems for prevention and coordination.

By aligning professional guidelines, technology and payment systems within an integrated CKM syndrome measurement framework, CKM syndrome care can become a coordinated, holistic and equitable continuum. This approach will not only improve patient outcomes; it will also strengthen accountability, reduce healthcare costs and create a foundation that supports active collaboration among providers, health plans and other stakeholders.

“CKM syndrome is one of the most pressing and complex challenges that clinicians, health systems and health plans face today,” says Nava. “The white paper provides an actionable roadmap for developing a CKM measurement framework that supports whole-person care, equity and sustainability.”

The insights and recommendations gathered from these convenings will guide NCQA in shaping a comprehensive quality improvement framework for CKM syndrome. As this work progresses, NCQA is eager to partner with national stakeholders to drive alignment, strengthen community collaborations and build consensus around a CKM-focused primary care framework for the next phase of this initiative.

To get involved in the next phase of this work, please contact Erin Oganesian, AVP, Corporate & Foundation Relations at eoganesian@ncqa.org.

Learn More

• Download the white papers: Advancing Care for Chronic Kidney Disease: Using Care Gaps to Inform a Quality Framework and Cardiovascular-Kidney-Metabolic Syndrome: Improving Quality of Care and Accountability.

Acknowledgments

Thank you to our panel of experts for sharing their knowledge and insights. This research is made possible with support from Boehringer Ingelheim and Novo Nordisk.