The health care industry is under constant pressure to reduce costs. This is especially evident in chronic disease management, where a growing segment of the population – the Centers for Disease Control estimates half of all adults in the United States have one or more chronic conditions – is accumulating an increasing portion of health care expenditures.
Researchers in the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery collaborate with different clinical areas at Mayo Clinic, jointly researching ways to address this. They seek to improve patient experience, outcomes and cost – adding value without sacrificing any of these aspects of care.
Finding value for patients with kidney failure
In a recent article in Population Health Management, a team of Mayo Clinic researchers led by Bjorg Thorsteinsdottir, M.D., an internal medicine doctor and health services researcher Priya Ramar, explored value in long-term dialysis (also called hemodialysis) care. They reported that for patients with end-stage kidney disease that receive maintenance dialysis, some interventions are more likely than others to have good results for patients.
“There is very little high quality evidence to guide dialysis practice reform to meet the challenges of new reimbursement standards,” said Dr. Thorsteinsdottir. “Through our research, we sought to collect, collate and share best practices for value-based care models.”
“Our findings confirm the importance of multidisciplinary care, and also support telemedicine as a means to increase access to providers and enhance patient outcomes,” she said. “Unfortunately there was insufficient evidence to measure the cost differential or value of these interventions.”
Knowledge synthesis – crunching the numbers
The team conducted a systematic review of all medical research studies published between 2000 and 2014, involving at least five adult dialysis patients, whose status was followed for at least six months. Of the 1,988 articles screened, 25 international studies with 74,833 maintenance dialysis patients were included in their study results.
They identified four intervention strategies used when treating patients needing ongoing dialysis that had been tested in comparison to standard care:
In most cases, these strategies were compared to standard urban dialysis center-delivered care. A complete breakdown of experiment and control groups in the included studies is listed in the study.
Teams Work for Patients
“When we analyzed the different approaches,” said Ramar, “All the strategies contributed to a decreased rate of death and hospitalization. However, only the use of multidisciplinary teams lowered death and hospitalization in a statistically significant manner.”
The seven studies in this subgroup included studies included pharmacists, nurses, social workers, dietitian case managers, nephrologists, or other team members, and regular meetings to discuss care plans. According to the authors, this finding is consistent with other research on patients with chronic kidney disease, including end stage renal disease, and across a variety of care providers and settings.
Telemedicine Seems to Help Too
Although they did not reach statistical significance, strategies that allowed for contact with a health care provider (telemedicine) and supported the patient’s self-care were associated with better outcomes than those that did not, according to the authors. Telemedicine was a strategy used in studies of home dialysis and dialysis in settings other than the patient’s home. Nocturnal (overnight during sleep) dialysis was also noted as a beneficial practice.
“This systematic review underscores the importance of multidisciplinary care,” say the authors, “And also the value of telemedicine as a means to increase access to providers and enhance outcomes for those dialyzing at home or in alternate settings, including those with limited access to nephrology expertise because of travel distance.”
While they conducted this research study to help identify and adapt best practices for value-based care in the Mayo Clinic dialysis network, their findings have a wider application for patients and health care providers everywhere. As with other types of knowledge synthesis research, these findings place best practice information at the fingertips of physicians – one paper to read rather than thousands. And for individuals diagnosed with end-stage kidney disease, this research can help them identify the best care options available, and learn what to ask for in discussions with their doctor.
The researchers also hope the findings will influence health insurers and government policymakers as they consider new reimbursement models.
For example, Dr. Thorsteinsdottir says, “The addition of telemedicine services to home dialysis appears to lead to better outcomes for patients, but except for rural patients receiving dialysis, this is not a reimbursable service.” She and her colleagues believe that adding more telemedicine capabilities within health care would add value for patients everywhere.
They also encourage more research, specifically prospective comparative effectiveness studies. “It is crucial that we study ongoing practice change that is happening in response to the new reimbursement models so that quality and patient safety are maintained,” says Dr. Thorsteinsdottir.
Dr. Thorsteinsdottir is an alumna of the Kern Health Care Delivery Scholar Program. Providing evidence-informed and patient-centered health care requires assessing existing health care delivery systems, rigorously testing different care models and applying best practices to improve those systems. This program trains and mentors clinically trained doctoral-level fellows and junior faculty in health services research, with the goal of transforming health care delivery for improved, patient-centered outcomes.
Other researchers involved in the study: