Association of the Comprehensive ESRD Care (CEC) Model with Treatment Adherence

Abstract

Background: Poor adherence to scheduled dialysis treatments is common and can cause adverse clinical and economic outcomes. In 2015, the Center for Medicare and Medicaid Innovation launched the Comprehensive End-Stage Renal Disease 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 1,037 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, though the effect was only marginally significant (OR=1.018, p=0.076). Effects were stronger among females (OR=1.028, p=0.062) than males (OR=1.010, p=0.485), and among those under 70 years (OR=1.024, p=0.040) than those 70+ (OR=0.999, p=0.963). The CEC was associated with higher odds of rescheduled sessions (OR=1.092, p<0.001). Effects were significant for both sexes, but were larger among males (OR=1.109, p<0.0001) than females (OR=1.070, p=0.012), and effects were significant among those under 70 years (OR=1.121, p<0.0001), but not those 70+ years (OR=0.990, p=0.796). 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 the success of these efforts, though the absolute magnitudes of the effects were modest.