Evaluating a Patient-Centered Medical Home for Patients Receiving Dialysis for Kidney Disease [Internet]

Excerpt

Background: The patient-centered medical home (PCMH) model has been proposed as a solution to fragmented care for patients requiring complex care. Patients with advanced kidney disease—with their high rates of morbidity, mortality, and health care use—have the potential to benefit from a PCMH model.

Objectives: To design, implement, and evaluate the effect of an adaptation of a PCMH model for patients receiving chronic hemodialysis for end-stage renal disease. The design was informed by patients, caregivers, and clinical stakeholders.

Methods: We implemented a PCMH for kidney disease at 2 dialysis centers over 18 months. To the standard hemodialysis team (comprising a nephrologist, nurse, social worker, dietitian, and dialysis technician), we added a primary care physician, pharmacist, nurse coordinator, and community health worker. The primary outcome was patient-reported kidney disease quality of life (KDQOL). Secondary outcomes included patient-reported self-efficacy and disease knowledge, depression (Patient Health Questionnaire-9 [PHQ-9]), satisfaction with dialysis care (Consumer Assessment of Health Care Providers and System for in Center Hemodialysis [CAHPS-ICH] survey), and primary care assessment (PCAS), clinical laboratory measurements, health care use, and staff perceptions (team vitality score). We used descriptive and orthogonal regression analysis for repeated measures for the primary and secondary outcomes. Sensitivity analyses addressed missing values.

Results: Of 248 eligible patients, 175 (71%) consented and participated; 97% were African American or Hispanic. At 12 and 18 months, the KDQOL mental component score improved from baseline (adjusted mean = 48.9; 95% CI, 47.14-50.73) by 2.5 (95% CI, 0.49-4.50; P = .01) and 2.8 (95% CI, 0.65-4.93; P = .01) points, respectively, adjusting for other factors. The KDQOL kidney disease effects improved from baseline (adjusted mean = 73.0; 95% CI, 69.38-76.53) to 6, 12, and 18 months by 4.3 (95% CI, 1.39-7.15; P = .004), 6.7 (95% CI, 3.63-9.74; P < .001), and 3.9 (95% CI, 0.51-7.29; P = .02), points, respectively, adjusting for other factors. KDQOL physical component summary and symptoms improved from baseline to 6 months only. PHQ-9 scores improved from baseline to 12 months; results for PCAS and CAHPS-ICH domains were mixed. Dialysis adequacy was stable. Inpatient and emergency department use at the primary medical center decreased.

Conclusions: This study is the first application of an adaptation of the PCMH for chronic hemodialysis patients. Patients in the study benefited from improved quality of life, particularly in the mental health and effects of kidney disease domains; improvements also occurred in some secondary outcomes. Benefits may need to be weighed against the relative costs of implementing an expanded care team. The findings should inform health care reorganization efforts aimed at improving outcomes for patients with complex chronic diseases.

Limitations and Subpopulation Considerations: As a before–after design and limited to 2 intervention sites with 1 group of academically based nephrologists, we cannot say with confidence that these effects were due to the intervention alone. With predominantly African American and Hispanic participants, results suggest that this model may be useful for a racially and ethnically diverse population. Information learned from this study can inform future study designs that include randomization at the site level with more than 1 clinical team and near–real time linkages with health care claims data.