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Study: Association of Chronic Condition Special Needs Plan with Hospitalization and Mortality among Patients with End Stage Kidney Disease

Chronic condition special needs plans (C-SNPs) are a type of Medicare Advantage plan offering targeted or specialized services for Medicare beneficiaries who have a severe or disabling chronic condition. The Centers for Medicare & Medicaid Services (CMS) included end stage kidney disease (ESKD) in the chronic or disabling conditions eligible for enrollment in C-SNPs. Our DaVita Clinical Research Group helped us evaluate the association of C-SNPs with outcomes among patients supported by DaVita Integrated Kidney Care teams.

Methods

This observational cohort study included patients newly enrolled in an ESKD C-SNP between Jan. 1, 2013, and Sept. 30, 2017, and receiving dialysis from DaVita Kidney Care. Patients were followed up until death, loss to follow-up or end of study (i.e., Dec. 31, 2018). C-SNP enrollees were matched via clinical and demographic characteristics with two different control populations: (1) patients in the same facilities or (2) patients in similar counties. The study outcomes included hospitalizations, mortality, specific laboratory values and Kidney Disease Quality of Life 36-item (KDQOL-36) survey scores.

Results

Baseline characteristicsin the facility-matched analysis were similar between the C-SNP and control groups (n = 2545 each) in terms of age, sex, distribution of race and ethnicity and other variables, e.g. percent of patients with diabetes. In the county-matched analysis, 1986 C-SNP enrollees were matched to patients, balancing the covariates between the 2 groups.

Hospitalizations. Hospitalization rates were 10% to 24% lower among C-SNP enrollees compared to controls, with an incidence rate ratio of 0.90 (95% confidence interval [CI] 0.84, 0.97) for patients in the same facility (A) and 0.76 (95% CI 0.70, 0.83) for patients in similar counties (B).

Mortality. The mortality rate for C-SNP enrollees was approximately 23% lower than that of controls, with a hazard ratio of 0.77 (95% CI 0.68, 0.88) for patients in the same facility (A) and 0.77 (95% CI 0.68, 0.88) for patients in similar counties (B), as illustrated below.

Other outcomes. There were no significant differences between C-SNP enrollees and matched patients with respect to serum calcium, phosphate, potassium, parathyroid hormone levels or KDQOL-36 survey scores.

Discussion

This analysis adds another piece of evidence in support of integrated care for patients with kidney disease. Although retrospective, it used a unique matching strategy to minimize confounding in determining that C-SNP enrollees had different hospitalization and mortality outcomes compared to patients not enrolled in C-SNPs.

Acknowledging the prevalence of Hispanics and African Americans in this study, Cohen et al identified an apparent benefit of C-SNP enrollment for individuals from minority racial and ethnic groups. Hispanic patients represented the largest proportions of patients in the study cohorts due, in part, to the geography of the C-SNPs studied. This is an important consideration as Hispanic individuals have a higher ESKD prevalence than non-Hispanic White individuals, and the disease process may yield differential mortality risk. Overall, these data suggest that C-SNP enrollment may provide greater access to care for patients from minority groups with effects on patient health and health care utilization.

In conclusion, this study found that C-SNP enrollment was associated with lower rates of hospitalization and mortality compared with similar patients who received ESKD care within the same facilities or within the same geographies but were not enrolled in C-SNPs. Aspects of the care model, including access to the integrated care team, regular interactions between this team, the patient’s nephrologist and the interdisciplinary dialysis team, and possibly access to the additional services and benefits provided via C‑SNPs, may improve ESKD patient outcomes.

Read the full study manuscript, which was published on JAMA Network Open, here.

Bryan Becker, MD, MMM, FACP, CPE

Bryan Becker, MD, MMM, FACP, CPE

Bryan N. Becker, MD, is chief medical officer of DaVita Integrated Care and has nearly 20 years of physician executive experience. He received his AB in English at Dartmouth College and MD from the University of Kansas, and, after training at Duke and Vanderbilt, he led the nephrology group at the University of Wisconsin and developed a new kidney care venture called Wisconsin Dialysis, Inc. He also served as CEO at the University of Illinois Hospital and Clinics and president of the National Kidney Foundation. Before joining DaVita Kidney Care, Dr. Becker served as President of the University of Chicago Medicine (UCM) Care Network, a more than 1,000 physician clinical integration organization, and Vice President, Clinical Integration and Associate Dean, Clinical Affairs at UCM. Twitter: @bnbeckermd