Toward Population Management in an Integrated Care Model

Franklin W. Maddux; Stephen McMurray; Allen R. Nissenson

doi:10.2215/CJN.09050912

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Table 1.

Effect of interventions in the ESRD Management Demonstration Project

DMO A

DMO B

DMO C

Impact of Pharmacist Involvement on Medication-Related Problems (Chapter 3)

Increase in medication-related problems over time

Management of CVD and Cardiovascular Risk Factors (Chapter 4)

Increase in ACEi/ARB use versus baseline among patients with congestive heart failure enrolled for one year, yet a decrease to below baseline at 2 years
No improvement in BP control among all enrollees

Improving Preventive Care Processes (Chapter 5)

More patients received influenza and pneumococcal vaccinations in 2007 and 2008 than in FFS
Significantly more patients with diabetes mellitus received routine HbA1c tests in accordance with established guidelines compared with FFS and a nationally representative population of HD patients (U.S. DOPPS) comparison populations
More patients with diabetes mellitus received routine foot and retinal examinations by mid-2008 compared with U.S. DOPPS

Improving Advanced Care Planning (Chapter 6)

Slight increase in adoption of ACP for HD patients versus baseline^a

Improving Diabetes Management (Chapter 7)

Increase in HbA1c tests for patients with diabetes mellitus during period of standing orders
Sharp decrease in HbA1c measurement among patients with diabetes mellitus after standing orders were discontinued
No significant change in achievement of the HbA1c target (HbA1c < 7%)

Changing Prescription Patterns of ACEi/ARB Use (Chapter 8)

Increase in ACEi/ARB use versus baseline among patients with persistent hypertension enrolled at least 2 years

Use of Oral Nutritional Supplement in Patients with Low Serum Albumin (Chapter 9)

Significantly reduced mortality among patients with the clinical indication to receive ONS as compared with the CMS ESRD Clinical Performance Project population
Increase in serum albumin among patients with the clinical indication to receive ONS.

Impact of Home Weight Monitoring on Clinical Outcomes (Chapter 10)

42% of all patients participated in the HWM program; however, 70% of 2006 enrollees used HWM and only 16% of 2007/2008 enrollees ever used HWM
Short-term effect of reducing IDWG for patients on HWM
No sustained effect of HWM in IDWG after discontinuation
HWM was associated with lower all-cause and cardiovascular mortality and all-cause and cardiovascular hospitalization for 2006 enrollees but this association was not noted for 2007–08 enrollees

DMO, disease management organization; ACP , advanced care plans; HD, hemodialysis; ONS, oral nutritional supplements; CMS, Centers for Medicare & Medicaid Services; CVD, cardiovascular disease; ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; HbA1c, hemoglobin A1c; HWM, home weight monitoring; IDWG, interdialytic weight gain; FFS, fee-for-service; CVD, cardiovascular disease; U.S. DOPPS, U.S. Dialysis Outcomes and Practice Patterns Study. Reprinted from reference 8.
↵a Analysis is limited by inconsistent ACP data, lack of an adequate comparison population, and the small number of patients included in the analyses.

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Table 2.

Outcome measures during the ESRD Management Demonstration Project

DMO A	DMO B	DMO C
No significant survival advantage over FFS at 1 and 2 years	Significant survival advantage over FFS at 1 year and 2 years	Significant survival advantage over FFS at 1 year and 2 years
No significant difference in all-cause and cardiovascular hospitalizations compared with FFS at 1 and 2 yearsHospital admission and readmission rates were not significantly different from FFSSignificantly fewer SNF stays and physician visits than FFSSignificantly higher rates of transplant wait-listing compared with FFS, but no significant difference in transplantation percentages compared with FFS	Significantly lower percentage of cardiovascular hospitalizations but not all-cause hospitalization compared with FFS at 2 years (possibly an artifact of limited data)Hospital admission rates were not significantly different from FFS; readmission rates exceeded FFSSignificantly fewer physician visits than FFSNo significant difference in ED visits or SNF stays compared with FFS over 3-year evaluation periodTransplantation rates were significantly lower than FFS by year 2 and transplant wait-listing rates were significantly lower compared with FFS	Significantly lower percentage of all-cause and cardiovascular hospitalizations compared with FFS at 1 and 2 yearsNo significant difference in hospital admission and readmission rates compared with FFS over the 3-year evaluation periodSignificantly fewer SNF stays and physician visits than FFS; no significant difference in ED visitsTransplantation rates were significantly lower than FFS, and no significant difference seen in transplant wait-listing in the Demonstration Project compared with FFS

Service utilization analyses were conducted with multiple methods; only results consistent across all methods are highlighted here. DMO, disease management organization; FFS, fee-for-service; SNF, skilled nursing facility; ED, emergency department. Reprinted from reference 8.