CKD quality improvement intervention with PCMH integration: health plan results

Am J Manag Care. 2019 Nov 1;25(11):e326-e333.


Objectives: To execute a chronic kidney disease (CKD) intervention to assess feasibility and preliminary outcomes for a health plan.

Study design: 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.

Methods: The study targeted the population at risk for CKD with diabetes and/or hypertension by implementing a care plan according to the stratification by estimated glomerular filtration rate (eGFR) and urinary albumin-creatinine ratio (uACR) or CKD heat map class.

Results: The population included 7420 individuals (51.8% female) with a mean age of 55.9 years; 19.1% had diabetes only, 42.2% had hypertension only, and 38.2% had both conditions. Overall, there was no change in eGFR testing among risk groups (84.8%), but a small significant increase in uACR testing occurred (from 31.3% to 33.0%; P = .0020). 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. Lastly, there were 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. Although there were increases in many of the per-member per-month costs assessed pre- versus post intervention, net savings in medical costs were $276.80 and $480.79 for CKD classes 3 and 5, respectively.

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

MeSH terms

  • Chronic Disease
  • Cost Control
  • Diabetes Complications / economics
  • Diabetes Complications / therapy
  • Feasibility Studies
  • Female
  • Glomerular Filtration Rate
  • Health Care Costs / statistics & numerical data
  • Humans
  • Hypertension / complications
  • Insurance, Health / trends*
  • Male
  • Middle Aged
  • Patient Readmission / statistics & numerical data
  • Patient-Centered Care
  • Quality Improvement*
  • Renal Insufficiency, Chronic / economics*
  • Renal Insufficiency, Chronic / therapy*
  • Risk Factors