Improved
p
Processes of Care for
End-Stage Renal Disease Patients
i a CMS Disease
in
Di
Management
M
t
Demonstration
Jeffrey
y Pearson, MS
Sylvia Ramirez, MD
Claudia Dahlerus, PhD
Christine Cheu,
Cheu MPP
Diane Frankenfield, DrPH
Bruce Robinson, MD
Brett Lantz, MA
Tania Chowdhury, MS
Sabrina Gomes
Gomes, BS
Introduction
• Disease Management
– System of coordinated healthcare interventions that
emphasize prevention of acute conditions and
complications
• The end-stage renal disease (ESRD) population
– Significant morbidity, mortality and cost
• Average 2 hospitalizations per patient per year
• Just under 20% of dialysis patients die each year
1 2% of the Medicare population; 5.8%
5 8% of the budget
• 1.2%
– Requires complex treatment plans because of multiple
comorbidities, management of renal replacement
therapies, and daily decisions about self-care (fluid
management, dietary intake, medication compliance)
2
Design of the ESRD Disease
Management Demonstration (1)
• CMS contracted with Medicare Advantage (MA) Plans to
d
develop
l
3 Disease
Di
Management
M
t programs
– DMO A: one MA Plan, one service area (CA)
– DMO B: two MA Plans
Plans, two service areas (GA
(GA, AZ)
– DMO C: four MA Plans, 11 service areas (NY, IL, MA, PA, TX, CT,
CA, TN, AL)
• Structure:
– DMO A and DMO C are operated by dialysis providers that
partnered with health plans
– DMO B’s partnering dialysis organization was acquired by the
dialysis provider for DMO A
• Each DMO generated their own hypotheses regarding
processes of care
3
Design of the ESRD Disease
Management Demonstration (2)
• Evaluation Period: January 2006 to December 2008
• Comparison Populations
– Di
Dialysis
l i patients
ti t in
i traditional
t diti
l FFS Medicare
M di
– Dialysis Outcomes and Practice Patterns Study (DOPPS)
– Clinical Performance Measures Project (CPM)
• Select analyses presented here; many others
4
Clinical and Demographic Characteristics (1)
Patients
Age: 18 to 44
45 to 59
60 to 74
75 +
Sex: Female
Male
Race: White
Black
Other
Hispanic/Latino
DMO A
DMO B
DMO C
All DMOs
FFS
722
19%*
39%*
34%*
8%*
39%*
39%
61%*
75%*
18%*
18%
7%*
57%*
268
20%*
37%*
37%*
6%*
50%
50%
33%*
57%*
57%
9%*
24%*
1,374
18%*
36%*
32%*
15%*
49%*
49%
51%*
50%*
45%*
45%
4%*
23%*
2,364
18%*
37%*
33%*
12%*
46%
54%
56%*
38%*
38%
6%*
34%*
477,246
13%
26%
36%
26%
46%
54%
60%
34%
6%
13%
* Numbers shown in yellow are significantly different from FFS (p < 0.05).
5
Clinical and Demographic Characteristics (2)
DMO A DMO B DMO C All DMOs
Patients
Months w/ ESRD
Less than 6
6 to 11
12 to 35
36 to 79
80 +
Cause of ESRD: Diabetes
Other
Modality: Hemodialysis
Peritoneal Dialysis
P i
Previous
F
Failed
il d T
Transplant
l t
CMS-HCC Risk Score
FFS
722
268
1,374
2,364
477,246
10%*
13%*
30%*
23%*
24%*
52%*
48%*
48%
96%*
4%*
9%*
1.05
7%*
7%*
34%*
19%*
33%*
46%
54%
100%*
0%*
7%
1.07
7%*
10%*
31%*
21%*
32%*
45%
55%
98%*
2%*
10%*
1.06
8%*
11%*
31%*
21%*
29%*
47%*
53%*
53%
98%*
2%*
9%*
1.06
48%
7%
19%
11%
16%
44%
56%
93%
7%
6%
1.06
* Numbers shown in yellow are significantly different from FFS (p < 0.05).
6
DMO A: Improving Preventive Care and
Diabetes Management Processes
• Background:
– Infections have been reported to contribute to 30%-36% of deaths
in patients on dialysis and that many of these are preventable by
greater vigilance in administering vaccinations
– ESRD patients with diabetes have higher comorbidity and poorer
outcomes compared to patients without diabetes - largely due to
increased risk of CVD which may be mitigated to a certain extent
by improved glycemic control
– Prior reports document low rates of implementation of various
preventive care measures in the ESRD population
• Methods:
– Analysis looked at vaccination rates for all patients
– Among patients with diabetes: foot/retinal exams and HbA1c tests
– Comparison groups were FFS patients (2008 USRDS Annual Data
Report) and U.S. DOPPS
7
DMO A: Influenza Vaccination Rates
DMO A Percent of Patients with Flu Vaccine Within One Year
FFS Percent of Patients with Flu Vaccine in 2006
100%
DMO A
80%
60%
FFS
40%
20%
0%
2006
2007
2008
2009
8
DMO A: Pneumococcal Vaccination Rates
DMO A Percent of Patients with Pneumococcal Vaccine within
Three Years
FFS Percent of Patients with Pneumococcal Vaccine in 2005-06
100%
80%
%
DMO A
60%
40%
20%
FFS
0%
2006
2007
2008
2009
9
DMO A: Diabetic Retinal Exam Rates
DMO A Percent of Diabetic Patients with Eye Exam Within One Year
U.S. DOPPS Percent of Diabetic Patients with Eye Exam Within One
Year
100%
80%
DMO A
60%
DOPPS
40%
20%
0%
2006
2007
2008
2009
10
DMO A: Diabetic Foot Exam Rates
DMO A Percent of Diabetic Patients with Foot Exam Within One Year
DOPPS Percent of Diabetic Patients with Foot Exam Within One Year
100%
DMO A
80%
DOPPS
60%
40%
20%
0%
2006
2007
2008
2009
11
DMO A: Quarterly
y HbA1c Testing
g
DMO A Percent of Diabetic Patients with HbA1c Test Within Three
Months
FFS Percent of Diabetic Patients with Four HbA1c Tests in 2006
100%
80%
DMO A
60%
FFS
40%
20%
0%
2006
2007
2008
2009
12
DMO A: Improving Preventive Care and
Diabetes Management Processes
• Limitations
– Process measures do not capture the entirety of diabetes or
immunization management
– Other diabetes and immunization processes of care
measures are not captured by the study design (e.g. HbA1c
level achievement of hepatitis B immunizations)
13
DMO B: Improving Advanced Care
Planning
• Background:
– Prior studies suggest
gg
that patients
p
with advanced
care plans (ACPs) were more likely to report higher
satisfaction with care
– Among dialysis patients, end-of-life decisions
involving discontinuing dialysis can contribute to
being with family rather than in hospital
• Methods:
– Living will,
will advanced directive,
directive power of attorney
– Four different assessments were used to assess
ACP status
– Comparison groups were DMO patients at first
y
data from U.S. DOPPS
review,, and facility-level
14
DMO B: Percent of Patients with an ACP
25%
20%
15%
10%
5%
0%
Feb-06
Aug-06
Feb-07
Aug-07
Feb-08
'
Aug-08 Dec-08
15
DMO B: Improving Advanced Care
Planning
• Black, American Indian/Alaska Native, and Hispanic
patients were less likely to have an ACP
• Among patients enrolled at least 12 months
presence of an ACP increased from 6.6% to 11.3%
– Published literature reports a range of 6-51%
– U.S. DOPPS facilities report 36%
• Limitations:
– U
Use off diff
differentt assessments
t and
d inconsistent
i
i t t data
d t
across assessments
– Lack of an adequate comparison population
16
DMO C: Use of Oral Nutritional Supplements
(ONS) in Patients with Low Serum Albumin
• Background
g
– Low serum albumin is a strong predictor of
morbidity and mortality in the ESRD population
• Methods:
– Patients with an average serum albumin <3.8 g/dL
were placed on ONS
– Treatment was 24 cans of Ensure Plus each month
• Starting in 2007, Glucerna for patients with diabetes
– ONS was discontinued once patients achieved a
three month average serum albumin >=3
three-month
>=3.8
8 g/dL
– Comparison group was patients with low serum
albumin in the ESRD CPM Project
17
DMO C: Use of ONS in Patients with Low
S
Serum
Albumin
Alb
i Levels
L
l
3.8
37
3.7
L3.6
d
/
g
3.5
n
i
m3.4
u
b
l 3.3
A
m
u
r 3.2
e
S3.1
Baseline 3.5-3.8 g/dL
B
Baseline
li <3.5
<3 5 g/dL
/dL
3
2.9
Month 1 and 2
and 2 (average)
3
4
5
6
7
8
Months Since Patient Enrollment
18
DMO C: Adjusted Hospitalization and
Mortality Percentages at One Year
Year, Among
Patients Indicated for ONS
Patients with serum
albumin < 3.8 g
g/dL at
baseline
Hospitalization
Percentage
g
(95% CI)
Mortality
Percentage
(95% CI)
DMO C (n=417)
71.8
(66 1 76.6)
(66.1,
76 6)
16.2
(11 8 20.3)
(11.8,
20 3)
ESRD CPM (n
(n=2425)
2425)
72.2
(70.0, 74.3)
23.4
(21.2, 25.4)
Adjusted for age at enrollment, race, ethnicity, years since ESRD onset at enrollment, and
diabetes as a comorbidity. Standardized to the overall average DMO C patient.
19
DMO C: Use of ONS in Patients with Low
Serum Albumin Levels
• Limitations
Li i i
– Does not isolate effect of ONS from overall
disease management
– Cost of ONS not analyzed
20
Conclusion: DM and Processes of Care (1)
• Patient Selection
– Clinical and demographic differences were noted
between Demonstration population and FFS
– Demonstration patients were younger but had ESRD
longer
– Racial
R i l and
d ethnic
th i makeup
k
diff
differed
d
– Si
Similar
il levels
l
l off comorbidity
bidit (as
( measured
d by
b CMSCMS
HCC risk score)
Conclusion: DM and Processes of Care (2)
( )
• Improvements
p
in preventive
p
care
– Influenza and pneumococcal vaccination rates
increased over time and exceeded rates in
comparison populations (DMO A)
– P
Proportion
i off patients
i
with
i h diabetes
di b
who
h received
i d
foot and retinal exams increased and was similar to
rates in comparison populations (DMO A)
– Percent of patients receiving quarterly HbA1c tests
consistently high (DMO A)
Conclusion: DM and Processes of Care (3)
( )
• Small improvement
p
in ACP measures
– Increase in patients with an ACP (DMO B)
• Improvement in nutritional markers and
associated clinical outcomes
– Early administration of ONS for enrollees with
indication showed increases in serum albumin and
lower risk of mortality (DMO C)
– No difference in hospitalization in main analysis,
th
though
h as-treated
t t d analysis
l i showed
h
d some
improvement (DMO C)
Additional Evaluation Components
•
•
•
•
•
Additional DMO-specific
p
hypotheses
yp
Patient-centered outcomes (QoL, satisfaction)
Hospitalization and mortality (overall and CVD)
Transplantation-related outcomes
Utilization of services
– Admissions, readmissions, total days hospitalized,
ED visits,
visits physician visits,
visits and SNF stays
• Costs to Medicare; potential savings to DMOs
• Provider satisfaction
24
CMS ESRD Managed Care (MC)
Demonstration
• Evaluated the impact of integrated system of care on
intermediate markers and clinical outcomes on patients
with ESRD, and the financial impact on CMS and MC sites
• Fi
Findings
di
– Significant reduction in mortality for only one (out of
remaining two) health plans
– No significant reduction in the rate of hospitalization in
the MC plans
– Patients who enrolled in MC plans did not experience
improved quality of life (QoL), however, respondents
reported overall satisfaction with MC programs
– CMS’s costs for the Demonstration enrollees appear to
h
have
been
b
greater
t under
d the
th Demonstration
D
t ti
than
th they
th
would have been if these enrollees had remained in the
FFS system
The Lewin Group and the University Renal Research and Education Association. Final Report on the Evaluation of
CMS’s ESRD Managed Care Demonstration. Report to CMS, June 2002, pgs 21-22.
25
ESRD Disease Management
Demonstration Evaluation: Objectives (1)
1. Characterize differences and commonalities in strategies across
ESRD Disease Management Organizations (DMOs)
2. Evaluate the impact of DMO-specific program components or
interventions in improving processes of care measures (and
outcomes for DMO C)
3 E
3.
Evaluate
l t the
th impact
i
t off Disease
Di
Management
M
t on improving
i
i the
th
following clinical outcomes:
•
Mortality
•
Time to Hospitalization (all-cause and cardiovascular)
•
Other Hospitalization Metrics
•
Utilization of other services: Emergency Department (ED) visits,
physician visits, skilled nursing facility (SNF) stays
•
Transplantation-related measures
26
ESRD DM Demonstration Evaluation:
Obj ti
Objectives
(2)
4. Evaluate the impact
p
of Disease Management
g
on QoL, patient
p
satisfaction and provider satisfaction
5. Evaluate the cost profile of the patients enrolling into the DMO
•
Did CMS pay more for DMO enrollees than it would have paid if
those beneficiaries had remained in the traditional FFS setting?
•
Did the
th DMO enrollees
ll
have
h
lower
l
utilization
tili ti than
th they
th would
ld have
h
had if they had remained in the traditional FFS setting, and what
are the estimated savings from any differences in utilization
27
Conclusion: DM and Processes of Care (3)
• Improvement
p
in preventive
p
care measures and
diabetes management revealed mixed findings
– Disease Management was successful in improving
diabetes-related process of care measures from
baseline, and was better than that observed for U.S.
DOPPS or FFS (DMO A)
– Initial improvement in diabetes management was
noted in DMO B, however, this declined after
operational processes resulted in discontinuation of
certain components