Preliminary Findings of a Chronic Disease Management Program in Medicare Advantage Enrollees with Mild to Moderate...

Chronic kidney disease (CKD) is traditionally viewed as a condition marked by a progressive reduction in kidney function leading to the need for kidney dialysis or transplantation. The estimated prevalence of CKD in adults in Puerto Rico is ~20% higher than that of the overall United States (US). To address the disproportionately high rate of CKD in Puerto Rico, we created a multidisciplinary chronic disease management (CDM) program targeting CKD and diabetes mellitus (DM), the leading CKD risk factor.

Over 7200 eligible enrollees in a Puerto Rico-Managed Medicare Program participated in a CDM program targeting individuals with CKD or DM as determined by administrative review. Evaluations were conducted on 4068 program participants with baseline glomerular filtration rate (eGFR) and codifying CKD stage by eGFR. A dietitian/nurse team provided dietary and lifestyle recommendations to the patient/family and a nephrologist/endocrinologist made diabetes and CKD recommendations to the primary care provider. Findings on 2095 participants with Stages 1-3 CKD with follow-up eGFR at least 6 months but less than 2 years after baseline are presented.

At baseline, the mean age was 74 years (range 30-101), 59% of patients were female and mean duration of follow-up from initial evaluation to second evaluation was 407 days (±159 days SD). Most participants had Stage 2 CKD (34.8%), followed by CKD Stage 1 and 3 (33.5 and 31.7%). During the follow-up period, 55.9% of participants with Stage 1 CKD remained in Stage 1, 84.9% of patients with Stage 2 remained in Stage 2 or regressed to Stage 1, while 96.1% of patients with Stage 3 remained in Stage 3 or regressed to Stage 2. Only 15.1% of patients in Stage 2 progressed to Stage 3 and 3.9% of patients in Stage 3 progressed to Stage 4 or 5. A secondary analysis comparing all 665 CDM Stage 3 participants to 117,249 historical controls found CDM participants demonstrated a higher rate of regression (20.3% vs. 15.2%; absolute difference +5.1 percentage points; p = <0.01) and a lower rate of progression (3.9% vs. 15.3%; absolute difference -11.4 percentage points; p < 0.001).

Early findings of a multidisciplinary CDM intervention indicate that 79% of participants with CKD Stages 1-3 by eGFR had stabilized or improved CKD status. Comparison to a randomized control group to better assess for causality and longer-term CDM program follow-up on CKD status and clinical outcomes is warranted.