NCQA Convenes Expert Panel on Cardiovascular-Kidney-Metabolic Syndrome

June 13, 2025 · Becky Kolinski

Cardiovascular, kidney and metabolic diseases affected more than 25% of the population between 2015 and 2020, and were the leading cause of death among U.S. adults in 2021. In 2023, the American Heart Association issued a Presidential Advisory that formally defined cardiovascular-kidney-metabolic (CKM) syndrome.

On May 28, 2025, NCQA convened a panel of experts—primary care clinicians, nephrologists, cardiologists, endocrinologists, pharmacists, researchers, patient representatives—to begin to develop a framework for enhancing the quality of care for people with CKM syndrome.

“CKM-related conditions affect a large portion of the population, and are responsible for some of the most severe health outcomes, including heart failure and end-stage renal disease,” says Caroline Blaum, NCQA’s Assistant Vice President, Chronic Conditions and Complex Care. “NCQA sees an opportunity to make a significant impact on population health by improving how these conditions are measured, managed and prevented.”

What Is CKM Syndrome?

CKM syndrome isn’t a disease—it’s a term that emphasizes the interconnection between cardiovascular disease, kidney disease and metabolic disorders like diabetes. These conditions often occur together, share common risk factors and respond to similar treatments.

Rather than treating them in isolation, CKM syndrome encourages a more holistic, patient-centered approach. By framing conditions as a unified syndrome, health care providers can better communicate with patients, streamline care and focus on prevention strategies that address all three conditions simultaneously.

The Growing Burden of CKM Syndrome

The American Heart Association estimates that 1 in 3 adults have three or more clinical, social or environmental risk factors that contribute to CKM diseases.

• Clinical risk factors. Obesity, diabetes, hypertension and smoking are the most common. Older adults are at higher risk—men tend to develop CKM syndrome earlier, while post-menopausal women face increased risk due to hormonal changes.
• Social risk factors. Access to care, financial stability and food security strongly influence CKM development and progression. Racial and ethnic disparities are significant: Black, Native American and Hispanic adults face higher rates of CKM-related conditions.
• Environmental risk factors. Lifestyle behaviors such as poor diet, physical inactivity, smoking and inadequate sleep contribute heavily. Chronic stress and mental health challenges also increase CKM risk and make disease management more difficult.

Opportunities to Improve CKM Care and Outcomes

“Measures that focus on prevention can be very powerful because if you can prevent one of these CKM-related diseases, it is likely that you can prevent them all,” says Blaum. “We’re very interested in exploring quality measures that focus on risk assessment and prevention.”

NCQA is interested in opportunities for improvement in several key areas.

1. Screening. Current screening approaches for CKM syndrome have limitations that reduce their effectiveness in early detection and risk stratification. One is the lack of standardized guidance for screening in children. Another relates to screening for social determinants of health, which can have a significant impact on prevention and progression of CKM syndrome.
2. Patient Engagement. Many patients are not aware that they have CKM-related conditions, or they’re not told in a way they can understand. Providing education and self-management support is essential because of the impact of social risks and lifestyle factors on disease progression.
3. Coordination of Care. CKM syndrome requires collaboration across multiple specialties, such as cardiology, nephrology and endocrinology, and with primary care. A lack of partnership across these disciplines can lead to fragmented care, with patients having to bridge the gaps between providers, leaving room for error and miscommunication.
4. Treatment Planning and Adherence. Treatment plans must be comprehensive, consistent with clinical guidelines and include clinical interventions, lifestyle modifications and supportive care strategies. An integrated care model can improve adherence by providing personalized support and guidance based on the needs of each patient.
5. Technology. Telemedicine and remote monitoring can be used between clinic visits to detect worsening symptoms, reducing the need for emergency interventions. Wearable devices and mobile apps can send data to providers—blood pressure, glucose levels, weight—that can be used to adjust treatment plans. Integrated EHR systems can help ensure that all clinicians have access to up-to-date medical records.

What’s Next

Panel findings will contribute to NCQA’s larger effort to develop a quality framework aimed at improving awareness and care quality for CKM syndrome.

“We’re in the early stages of exploration,” says Blaum. “The purpose of the expert panel was to generate ideas and lay the groundwork for future recommendations. As our research evolves, we will move toward more actionable strategies to transform care delivery and quality measurement for CKM syndrome.”

Acknowledgments

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