# Preliminary Findings of a Chronic Disease Management Program in Medicare Advantage Enrollees with Mild to Moderate Kidney Disease

## TL;DR

A multidisciplinary care program for early-stage kidney disease in Puerto Rico shows most patients stabilized or improved, offering a promising model for managing chronic kidney disease in under-resourced populations.

## Contribution

Demonstrates that a large-scale chronic disease management program can stabilize or improve CKD in over 79% of patients in a high-risk, under-resourced population.

## Key findings

- 96.1% of Stage 3 CKD patients remained in Stage 3 or regressed to Stage 2 during follow-up.
- CDM participants showed a 5.1 percentage point higher regression rate and 11.4 percentage point lower progression rate compared to historical controls.
- 79% of CKD Stages 1–3 patients stabilized or improved after multidisciplinary care.

## Abstract

Public health relevance—How does this work relate to a public health issue?
Chronic kidney disease (CKD) represents a major public health issue in Puerto Rico, where prevalence and progression rates exceed those of the continental United States. This is largely impacted by high diabetes prevalence, structural healthcare inequities, and limited access to specialty care.Our work directly addresses the public health challenge of CKD progression by evaluating a large-scale multidisciplinary chronic disease management program designed to improve early detection, care coordination, and disease stabilization in an under-resourced population.

Chronic kidney disease (CKD) represents a major public health issue in Puerto Rico, where prevalence and progression rates exceed those of the continental United States. This is largely impacted by high diabetes prevalence, structural healthcare inequities, and limited access to specialty care.

Our work directly addresses the public health challenge of CKD progression by evaluating a large-scale multidisciplinary chronic disease management program designed to improve early detection, care coordination, and disease stabilization in an under-resourced population.

Public health significance—Why is this work of significance to public health?
By demonstrating that over 90% of real-world patients with CKD stages 2–3 experienced stabilization or improvement in renal function, our work provides evidence that early, coordinated interventions can meaningfully alter CKD trajectories at the population level.Our findings are particularly significant for public health because they highlight an effective care model within Puerto Rico’s complex Medicare Advantage and health system barriers, addressing a population historically underrepresented in CKD research.

By demonstrating that over 90% of real-world patients with CKD stages 2–3 experienced stabilization or improvement in renal function, our work provides evidence that early, coordinated interventions can meaningfully alter CKD trajectories at the population level.

Our findings are particularly significant for public health because they highlight an effective care model within Puerto Rico’s complex Medicare Advantage and health system barriers, addressing a population historically underrepresented in CKD research.

Public health implications—What are the key implications or messages for practitioners, policy makers and/or researchers in public health?
For practitioners, the results support early nephrology engagement and multidisciplinary care as critical strategies to prevent CKD progression, reduce possible dialysis burden, and improve outcomes even in high-risk populations like the elderly.For policymakers and researchers, our study provides preliminary evidence to expand and sustain Medicare Advantage based chronic disease management programs, even in structurally disadvantaged settings. Longer term evaluation on outcomes on morbidity, mortality, and cost-effectiveness will hopefully further support investing in a multidisciplinary care model for patients with early-stage CKD.

For practitioners, the results support early nephrology engagement and multidisciplinary care as critical strategies to prevent CKD progression, reduce possible dialysis burden, and improve outcomes even in high-risk populations like the elderly.

For policymakers and researchers, our study provides preliminary evidence to expand and sustain Medicare Advantage based chronic disease management programs, even in structurally disadvantaged settings. Longer term evaluation on outcomes on morbidity, mortality, and cost-effectiveness will hopefully further support investing in a multidisciplinary care model for patients with early-stage CKD.

Background: Chronic kidney disease (CKD) is traditionally viewed as a condition marked by a progressive reduction in kidney function leading to the need for kidney dialysis or transplantation. The estimated prevalence of CKD in adults in Puerto Rico is ~20% higher than that of the overall United States (US). To address the disproportionately high rate of CKD in Puerto Rico, we created a multidisciplinary chronic disease management (CDM) program targeting CKD and diabetes mellitus (DM), the leading CKD risk factor. Methods: Over 7200 eligible enrollees in a Puerto Rico-Managed Medicare Program participated in a CDM program targeting individuals with CKD or DM as determined by administrative review. Evaluations were conducted on 4068 program participants with baseline glomerular filtration rate (eGFR) and codifying CKD stage by eGFR. A dietitian/nurse team provided dietary and lifestyle recommendations to the patient/family and a nephrologist/endocrinologist made diabetes and CKD recommendations to the primary care provider. Findings on 2095 participants with Stages 1–3 CKD with follow-up eGFR at least 6 months but less than 2 years after baseline are presented. Results: At baseline, the mean age was 74 years (range 30–101), 59% of patients were female and mean duration of follow-up from initial evaluation to second evaluation was 407 days (±159 days SD). Most participants had Stage 2 CKD (34.8%), followed by CKD Stage 1 and 3 (33.5 and 31.7%). During the follow-up period, 55.9% of participants with Stage 1 CKD remained in Stage 1, 84.9% of patients with Stage 2 remained in Stage 2 or regressed to Stage 1, while 96.1% of patients with Stage 3 remained in Stage 3 or regressed to Stage 2. Only 15.1% of patients in Stage 2 progressed to Stage 3 and 3.9% of patients in Stage 3 progressed to Stage 4 or 5. A secondary analysis comparing all 665 CDM Stage 3 participants to 117,249 historical controls found CDM participants demonstrated a higher rate of regression (20.3% vs. 15.2%; absolute difference +5.1 percentage points; p = <0.01) and a lower rate of progression (3.9% vs. 15.3%; absolute difference −11.4 percentage points; p < 0.001). Conclusions: Early findings of a multidisciplinary CDM intervention indicate that 79% of participants with CKD Stages 1–3 by eGFR had stabilized or improved CKD status. Comparison to a randomized control group to better assess for causality and longer-term CDM program follow-up on CKD status and clinical outcomes is warranted.