Disease Management Program Reduces Hospital Days for Chronic Renal Disease Patients
From 1997 to 2000, researchers at the Brandeis University Institute for Health Policy supported a study of the renal disease management program operated by Southern California Kaiser Permanente, a regional, nonprofit HMO.
The program featured routine screening for kidney disease, care provided by a multidisciplinary team, and treatment guided by disease management protocols.
The study compared outcomes of patients with end-stage renal disease treated by the HMO to patient outcomes achieved by Medicare fee-for-service providers.
- Kaiser patients with end-stage renal disease were seen earlier and more regularly by kidney specialists than were the fee-for-service patients.
- Kaiser patients used significantly fewer hospital days in the year prior to diagnosis with end-stage renal disease than did fee-for-service patients (12 days vs. 16.6 days). They also used significantly fewer hospital days in the year following diagnosis (17 days vs. 28.2 days).
The Robert Wood Johnson Foundation (RWJF) supported this project through a grant of $293,612.
As the number of people with chronic diseases is expected to increase over the coming years, public officials are seeking innovative approaches to managing health care costs associated with these diseases. Chronic renal insufficiency (CRI), a decline in kidney function leading to end-stage renal disease (ESRD), is particularly costly in that it requires ongoing dialysis or transplant to sustain life.
More than 90 percent of these costs are borne by Medicare, which frequently pays for the costliest phase of a disease even though earlier intervention might have reduced costs and improved quality of life. There have been few rigorous studies that compare patients with chronic diseases who participate in managed care programs with matched patients who receive health care through traditional FFS programs.
Before the RWJF grant, Brandeis University investigators designed a demonstration for the federal Health Care Financing Administration (HCFA) (now called the Centers for Medicare & Medicaid Services [CMS]) for Medicare-eligible patients with ESRD. The investigators sought additional funds from RWJF to examine in greater depth ESRD patients receiving treatment through a renal disease management program operated by the SCKP health care system.
SCKP was selected as the focus of the study because: Its renal disease management program had been operating since the 1980s.
- It provided an opportunity for researchers to contrast managed care with traditional FFS approaches to people with CRI.
- It served large numbers of people with ESRD, thus allowing sufficient sample size from which to draw conclusions.
- It had already collected some data that suggested its managed care approach resulted in better patient outcomes than Medicare's traditional FFS approach.
The study had two goals: to document Kaiser's clinical and managerial approaches to kidney disease; and to compare cost and quality outcomes achieved by SCKP and Medicare FFS.
The Schneider Institute for Health Policy at Brandeis University contributed approximately $125,000 in financial and in-kind support for the project.
To document SCKP's clinical and management approaches, researchers visited 9 of 12 medical centers in the SCKP system, and at each center, interviewed at least one nephrologist (kidney specialist), as well as other clinical and administrative staff. They also visited an FFS ESRD program in Massachusetts and interviewed care providers there.
To evaluate cost and quality of outcomes, the study team collected and analyzed data on Kaiser patients with onset of ESRD between 1993 and 1997. For comparison, they examined data on FFS patients contained in the United States Renal Data system (USRDS), a national data system that collects, analyzes, and distributes information about ESRD in the U.S. The major outcome measured was the number of days of hospital care used by patients during the first year on dialysis. In addition, researchers compared utilization patterns for both groups of patients for a year prior to their ESRD diagnosis.
The investigators documented these key features of SCKP's approach to managing kidney disease:
- Kaiser patients are routinely screened for renal disease to increase the likelihood of early detection.
- Kidney disease patients are treated by multidisciplinary teams that include those specialists required to deliver care. Team leaders create and communicate a shared vision, they foster teamwork on behalf of the patient, and they determine how to allocate and secure resources. Team members include: a nephrologist, a renal case manager, a renal dietician, a renal social worker, and a renal pharmacist.
- Nephrologists serve on site as salaried primary care physicians, and dialysis is provided on site.
- SCKP employs disease management protocols to improve and maintain patient health. These protocols not only address maintaining kidney function, but also include managing co-morbid conditions such as hypertension and diabetes, and evaluating and managing vascular access (for example, protecting the dominant arm from IV lines and blood drawing). Protocols also address modifying the patient's lifestyle, including weight control, smoking cessation, and exercise.
The investigators documented the following differences in outcomes between Kaiser and FFS Medicare patients:
- SCKP patients with ESRD were seen earlier and more regularly by kidney specialists than were the FFS patients. Compared with FFS Medicare patients, nephrologists saw SCKP patients earlier in the disease process and more regularly throughout the pre-ESRD period. One-half of the ESRD patients at SCKP had not seen a nephrologist in the pre-ESRD phase, while nearly three-quarters of FFS patients had not seen a nephrologist during that time.
- In the year prior to onset of ESRD, and in the first year after onset, SCKP patients used fewer hospital days compared with FFS patients. SCKP patients used an average of 12 hospital days one year prior to onset of ESRD, and 17 hospital days one year after the onset of ESRD. FFS patients used 16.6 hospital days during the year prior to onset of ESRD, and 28.2 hospital days during the year after onset of ESRD. These differences persisted even after the researchers controlled for other factors that could contribute to hospital use, such as diabetes and cardiovascular conditions.
Investigators prepared two reports and published one article in The Milbank Quarterly detailing their findings (see the Bibliography for details). They also presented their work at the June 2000 annual conference of the Association for Health Services Research and at the October 2000 annual meeting of the American Society of Nephrologists.
GRANT DETAILS & CONTACT INFORMATION
Assessment of Efforts to Provide Comprehensive Management of Chronic Renal Disease
Brandeis University, Florence Heller Graduate School for Advanced Studies in Social Welfare (Waltham, MA)
Dates: August 1997 to June 2000
Stanley S. Wallack, Ph.D.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Wallack S, Trisolini M, Bhalotra S, et al. Reforming the Medicare ESRD Program. Waltham, Mass.: Schneider Institute for Health Policy, Brandeis University. Prepared for The Robert Wood Johnson Foundation, August 31, 1998.
Tompkins CP, Bhalotra S, Wallack S, et al. An Evaluation of Chronic Disease Management in Managed Care: The Case of Chronic Renal Failure. Waltham, Mass.: Schneider Institute for Health Policy, Brandeis University. Prepared for The Robert Wood Johnson Foundation, August 22, 2000.
Tompkins CP, Bhalotra S, Trisolini, M, Wallack SS, Rasgon S, and Yeoh H. "Applying Disease Management Strategies to Medicare." Milbank Quarterly, 77(4): 461484, 1999. Abstract available online.
Presentations and Testimony
Rasgon S, Yeoh H, Bhalotra S, et al. "Management of Chronic Disease: The Kaiser Experience with Chronic Renal Failure." Presented at the annual meeting of the American Society of Nephrologists, October 2000, Toronto, Canada.
Tompkins C and Bhalotra S. "Improving the Quality of Care for Chronic Renal Disease." Poster presentation at the annual conference of the Association for Health Services Research, June 2000, Los Angeles, Calif.
Report prepared by: Jan Hempel
Reviewed by: Mary Nakashian
Reviewed by: Richard Camer
Program Officer: Seth L. Emont