Association of the Comprehensive ESRD Care Model with Treatment Adherence.

Background: Poor adherence to scheduled dialysis treatments is common and can cause adverse clinical and economic outcomes. In 2015, the Centers for Medicare and Medicaid Innovation launched the Comprehensive ESRD Care (CEC) Model, a novel modification of the Accountable Care Organization framework. Many model participants reported efforts to increase dialysis adherence and promptly reschedule missed treatments.
Methods: With Medicare databases covering 2014-2019, we used difference-in-differences models to compare treatment adherence among patients aligned to 1037 CEC facilities relative to those aligned to matched comparison facilities, while accounting for their differences at baseline. Using dates of service, we identified patients who typically received three weekly treatments and the days when treatments typically occurred. Skipped treatments were defined as days when the patient was not hospitalized but did not receive an expected treatment, and rescheduled treatments as days when a patient who had skipped their previous treatment received an additional treatment before their next expected treatment date.
Results: Patients in the CEC Model had higher odds of attending as-scheduled sessions relative to the comparison group, although the effect was only marginally significant (OR, 1.02; 95% CI, 1.00 to 1.04, P =0.08). Effects were stronger among females (OR, 1.03; 95% CI, 1.00 to 1.06, P =0.06) than males (OR, 1.01; 95% CI, 0.98 to 1.04, P =0.49), and among those aged <70 years (OR, 1.02; 95% CI, 1.00 to 1.05, P =0.04) than those aged ≥70 years (OR, 1.00; 95% CI, 0.96 to 1.04, P =0.96). The CEC was associated with higher odds of rescheduled sessions (OR, 1.09; 95% CI, 1.05 to 1.14, P <0.001). Effects were significant for both sexes, but were larger among males (OR, 1.11; 95% CI, 1.05 to 1.18, P <0.001) than females (OR, 1.07; 95% CI, 1.02 to 1.13, P =0.01), and effects were significant among those <70 years (OR, 1.12; 95% CI, 1.07 to 1.17, P <0.001), but not those ≥70 years (OR, 0.99; 95% CI, 0.92 to 1.07, P =0.80).
Conclusions: The CEC Model is intended to incentivize strategies to prevent costly interventions. Because poor dialysis adherence may precipitate hospitalizations or other adverse events, many CEC Model participants encouraged adherence and promptly rescheduled missed treatments as strategic priorities. This study suggests these efforts were a success, although the absolute magnitudes of the effects were modest.
Competing Interests: A. Ackerman reports having an ownership interest in UnitedHealth Group. B. Negrusa reports having an ownership interest because Lewin employees are entitled to receive UnitedHealth Groups stock. C. Dahlerus reports being a scientific advisor or member through serving as a Guest Editor with the journal Medical Care for a 2019 supplement on patient-reported outcomes scoring methodologies. D. Strubler reports having an ownership interest in GlaxoSmithKline and Sanofi. D. Ullman reports having an ownership interest in UnitedHealth Group. J. Segal reports being a scientific advisor or member of the ESRD Network 11 Medical Review/Executive Committees. J. Wiens reports having an ownership interest in UnitedHealth Group. R. Braun reports having an ownership interest in UnitedHealth Group. R. Hirth reports being a scientific advisor or member on the Board of Directors of the Association of University Programs in Health Administration, Deputy Editor of Medical Care, and the Editorial Board of the American Journal of Managed Care. All remaining authors have nothing to disclose.
(Copyright © 2022 by the American Society of Nephrology.)