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PCMH Integration Proves Beneficial for Improving CKD Outcomes

November 21, 2019

A group of researchers, lead by Joseph Vassalotti, MD and colleagues, found that a scalable chronic kidney disease (CKD) intervention was feasible and also improved patient outcomes. They published their study findings online in the American Journal of Managed Care.  

This CKD quality improvement study was incorporated into an existing CareFirst primary care patient-centered medical home cohort with a pre- and postintervention assessment from July 1, 2015, to June 30, 2017,” Dr Vassalotti and colleagues explained.

In order to execute a CKD intervention to assess both feasibility and preliminary outcomes for a health plan, the research team targeted a population at risk for CKD with diabetes and/or hypertension. They estimated glomerular filtration rate (eGFR) and urinary albumin-creatinine ratio (uACR) or CKD heat map class in order to implement a care plan.  

Based on their criteria, Dr Vassalotti and colleagues identified 7420 study participants. Of these participants, 51.8% were female, the average age was 55.9 years, 19.1% had diabetes only, 42.2% had hypertension only, and 38.2% had both conditions. 

According to the study findings, there was no change in eGFR testing among risk groups (84.8%). However, the researchers found a small but significant increase in uACR testing that occurred (from 31.3% to 33.0%; P = .0020). Further, reductions in admissions per 1000 patients were from 362.5 to 249.0 for class 3, 311.7 to 219.2 for class 4, and 590.9 to 323.5 for class 5. In addition, the researchers identified reductions in 30-day readmissions per 1000 patients, from 51.9 to 13.7 for class 4 and 45.5 to 0 for class 5.  

Finally, the results of the study showed that there were increases in many of the per-member per-month costs assessed. However, net savings in medical costs were $276.80 and $480.79 for CKD classes 3 and 5, respectively. 

“This scalable CKD intervention demonstrated feasibility. For advanced CKD, decreased hospitalization and a reduction in several important costs were observed,” Dr Vassalotti and colleagues concluded. “These preliminary results support the stratification of laboratory data for CKD population health innovation in commercial health plans.”  

Julie Gould  

Vassalotti JA, DeVinney R, Lukasik S, et al. CKD quality improvement intervention with PCMH integration: health plan results [Published online November 1, 2019]. Am J Manag Care. 2019;25(11):e326–e333.

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