C-SNP Enrollment Improves Outcomes for Patients with ESKD

The Centers for Medicare & Medicaid Services chronic conditions special needs plans (C-SNPs) are a type of Medicare Advantage plan that include targeted or specialized  services for Medicare beneficiaries who have a severe or disabling chronic condition. End-stage kidney disease (ESKD) is included among the chronic or disabling conditions eligible for enrollment in C-SNPs. The plan receives payments per member per month and is at risk for coordinating and managing the care of enrolled individuals. Specific benefits and healthcare networks for the beneficiaries may also be offered; these may vary based on the plan and may include access to preventive vision and dental services, nutrition support, and access to transportation.

Bryan N. Becker, MD, and colleagues conducted a multicenter cohort study to examine whether and to what extent enrollment in a C-SNP was associated with improved clinical outcomes and quality of life among patients with ESKD. Results of the study were reported in JAMA Network Open [doi:10.1001/jamanetworkopen.2020.23663].

The primary outcomes and measures in the study were hospitalizations, mortality, laboratory values indicative of metabolic control, and Kidney Disease Quality of Life 36-item (KDQOL-36) survey scores. Eligible patients were newly enrolled in an ESKD C-SNP between January 1, 2013, and September 30, 2017, and receiving dialysis from DaVita Kidney Care. Follow-up continued until death, loss of follow-up, or end of study (12/31/2018).

Patients with ESKD enrolled in a C-SNP were matched via multiple clinical and demographic characteristics with two different control populations: (1) those in the same facilities (n=2545); or (2) those in similar counties (n=1986). Exclusion criteria included enrollment in CareMore C-SNPs (n=206).

A total of 2718 C-SNP enrollees met inclusion criteria. Of those, 2545 were matched to patients in the facility-matched analysis. At baseline, characteristics of the C-SNP and control groups were similar in age (mean, 57.2 years vs 57.1 years), sex (38.0% women vs 39.2% women), distribution of race (21.7% Black vs 21.1% Black), and ethnicity (52.2% Hispanic vs 53.1% Hispanic), respectively. The two groups were also similar in body mass index (mean 27.7 vs 27.7), etiology of kidney disease (e.g., diabetes, 48.9% vs 48.2%), and vintage (mean 46.3 months vs 48.0 months) (standardized difference <10% for all characteristics). The study population included more than 50% Hispanic patients, and Hispanic and Black patients accounted for nearly 75% of the cohort. The ESKD etiology reflected the distribution in data from the United States Renal Data System.

In the county-matched analysis, 1986 C-SNP enrollees were matched to control patients. At baseline, mean age of C-SNP enrollees compared with controls was 57.8 years versus 58.1 years, 35.5% women versus 35.5% women, 54.6% Hispanic versus 54.6% Hispanic, and 23.8% Black versus 23.8%.

Compared with non-C-SNP enrollees, those enrolled in a C-SNP had lower rates of hospitalization: incidence rate ratios were 0.90 (95% confidence interval [CI], 0.84-0.97; P=.006) in the facility-matched analysis and 0.76 (95% CI, 0.70-0.83; P<.001) in the county-matched analysis.

In both analyses, most patients were receiving in-center hemodialysis. There were no significant differences between C-SNP enrollees and matched patients in frequent comorbid cardiovascular, respiratory, or vascular conditions.

In the facility-matched analysis, C-SNP enrollees had 6141 hospital admissions during 55,561 patient-months of follow-up, for a hospitalization rate of 11.05 per 100 patient-months. Among matched controls, there were 6551 hospital admissions in 53,408 patient-months of follow-up, for a hospitalization rate of 12.27 per 100 patient-months. The incidence rate ratio for hospitalization was 0.90 (95% CI, 0.84-0.97; P=.006).

In the county-matched analysis, C-SNP enrollees had 4625 admissions in 44,553 patient-months of follow-up, for a hospitalization rate of 10.38 per 100 patient-months. Matched patients experienced 6348 admissions in 46,704 patient-months of follow-up, for a hospitalization rate of 13.59 per 100 patient-months. The corresponding incidence rate ratio was 0.76 (95% CI, 0.70-0.83; P<.001), favoring C-SNP enrollees.

In mortality analyses, there were 440 deaths during 55,561 patient-months of follow-up among C-SNP enrollees in the facility-matched cohort (mortality rate, 0.79 per 100 patient-months).  There were 543 deaths among matched patients during 53,408 patient-months of follow-up (mortality rate, 1.02 per 100 patient-months). The hazard ratio (HR) for mortality among C-SNP enrollees was significantly lower than for matched controls (0.77; 95% CI, 0.68-0.88; P<.001).

In the county-matched analysis, there were 337 deaths during 44,553 patient-months of follow-up among C-SNP enrollees, for a mortality rate of 0.76 per 100 patient-months. In the matched patient cohort, there were a total of 461 deaths during 46,704 patient-months of follow-up, for a mortality rate of 0.99 per 100 patient-months. The HR for mortality was significantly lower among C-SNP enrollees compared with controls in the same counties (0.77; 95% CI, 0.66-0.88; P<.001).

There were no significant differences between C-SNP enrollees and matched patients in the same facilities in calcium, potassium, or parathyroid levels. There was a small but significant difference in phosphate levels; C-SNP enrollees had lower mean phosphate levels than the matched patients (5.4 [95% CI, 5.3-5.4] vs 5.5 [95% CI, 5.4-5.5] mg/dL; P=.04). There were no significant differences in any laboratory parameters between C-SNP enrollees and matched patients in the same counties.

In analysis of KDQOL-36 scores, there were no significant differences between C-SNP enrollees and matched patients in the same facilities or in similar counties.

Limitations to the findings cited by the authors included potential confounding by the populations as well as facility-level differences in care and care team member complement, the inability to account for potential shifts in physician coverage of patients and hospital programs during the study’s timeframe, and concentrating the study population in select geographies, possibly limiting the applicability of the findings beyond those geographies.

In conclusion, the researchers said, “The data in this analysis suggested that enrollment in a C-SNP was associated with lower rates of hospitalization and mortality compared with similar patients who received ESKD care within the same facilities or within the same geographies but were not enrolled in C-SNPs. This suggests that aspects of the care model, including access to the integrated care team, regular interactions between this team and the interdisciplinary dialysis team (e.g., the patient’s nephrologist), and possible access to the additional services and benefits provided via C-SNPs, may improve patient outcomes beyond the standard of care for this high-risk, high-need population.”

Takeaway Points

  1. Researchers conducted a retrospective multicenter cohort study to assess whether enrollment in a chronic condition special needs plan (C-SNP) improved outcomes among patients with end-stage kidney disease (ESKD).
  2. Compared with non-enrollees, those who enrolled in a C-SNP had lower rates of hospitalization and mortality, in both facility-matched and county-matched analyses.
  3. The researchers said the findings suggest that the additional services and benefits of C-SNP enrollment may improve outcomes compared with standard of care of ESKD.