A System-Wide Population Health Value Approach to Reduce Hospitalization Among Chronic Kidney Disease Patients: an Observational Study

• Published in: Journal of general internal medicine : JGIM 2021-06, Vol.36 (6), p.1613-1621
• Main Authors: Gupta, R., Skootsky, S. A., Kahn, K. L., Chen, L., Abtin, F., Kee, S., Nicholas, S. B., Vangala, S., Wilson, J.
• Format: Article
• Language: English
• Subjects: Aged; COVID-19; Electronic health records; Electronic medical records; Emergency medical care; Emergency medical services; Emergency Service, Hospital; Evaluation; Expenditures; Government programs; Health care; Health care facilities; Health services utilization; Hospitalization; Humans; Infrastructure; Internal Medicine; Intervention; Kidney diseases; Kidneys; Leadership; Medicare; Medicine; Medicine & Public Health; Morbidity; Observational studies; Original Research; Population; Population Health; Populations; Regression analysis; Renal Insufficiency, Chronic - epidemiology; Renal Insufficiency, Chronic - therapy; SARS-CoV-2; United States; Utilization
• ISSN: 0884-8734; 1525-1497
• DOI: 10.1007/s11606-020-06272-5

Background Chronic kidney disease (CKD) is a leading cause of healthcare morbidity, utilization, and expenditures nationally, and caring for late-stage CKD populations is complex. Improving health system efficiency could mitigate these outcomes and, in the COVID-19 era, reduce risks of viral exposure. Objective As part of a system-wide transformation to improve healthcare value among populations with high healthcare utilization and morbidity, UCLA Health evaluated a new patient-centered approach that we hypothesized would reduce inpatient utilization for CKD patients. Design For 18 months in 2015–2016 and 12 months in 2017, we conducted an interrupted time series regression analysis to evaluate the intervention’s impact on inpatient utilization. We used internal electronic health records and claims data across six payers. Participants A total of 1442 stage 4–5 CKD patients at a large academic medical center. Intervention Between October and December 2016, the organization implemented a Population Health Value CKD intervention for the CKD stages 4–5 population. A multispecialty leadership team risk stratified the population and identified improvement opportunities, redesigned multispecialty care coordination pathways across settings, and developed greater ambulatory infrastructure to support care needs. Main Measures Outcomes included utilization of hospitalizations, emergency department (ED) visits, inpatient bed days, and 30-day all-cause readmissions. Key Results During the 12 months following intervention implementation, the monthly estimated rate of decline for hospitalizations was 5.4% (95% CI: 3.4–7.4%), which was 3.4 percentage points faster than the 18-month pre-intervention decline of 2.0% (95% CI: 1.0–2.2%) per month ( p  = 0.004). Medicare CKD patients’ monthly ED visit rate of decline was 3.0% (95% CI: 1.2–4.8%) after intervention, which was 2.6 percentage points faster than the pre-intervention decline of 0.4% (95% CI: − 0.8 to 1.6%) per month ( p  = 0.02). Conclusions By creating care pathways that link primary and specialty care teams across settings with increased ambulatory infrastructure, healthcare systems have potential to reduce inpatient healthcare utilization.