A Retrospective Multi-site Examination of Chronic Kidney Disease Using Longitudinal Laboratory Results and Metadata to Identify Clinical and Financial Risk

Abstract

(350 words) Background: A retrospective, non-experimental, non-interventional study was conducted at 3 health care organizations to identify clinical gaps in care for patients with stage 3 or 4 chronic kidney disease (CKD), and financial opportunity from risk adjustment payment systems. Lack of evaluation for CKD in patients with diabetes was also assessed. Methods: Outpatient longitudinal laboratory results and patient metadata available in the electronic medical record, laboratory information system, and/or laboratory billing or facility claims data for the calendar year 2021 were evaluated. Laboratory results were compared to billing data (ICD-10 codes) and risk adjustment scores including Hierarchical Condition Categories (HCCs) to determine if laboratory-identified CKD was coded as a disease condition in the electronic medical record. Adults 18 to 75 years of age were included; inpatient laboratory results and pregnant women were excluded. Results: At the 3 institutions, 12478 of 16063 (78%), 487 of 1511 (32%) and 19433 of 29277 (66%) of patients with laboratory evidence of stage 3 or 4 CKD did not have a corresponding ICD10 or HCC code for CKD in the electronic medical record. For patients with diabetes on the basis of an HbA1c value of >6.5%, 34384 of 58278 (59%), 2274 of 2740 (83%) and 40378 of 52440 (77%) had not undergone guideline-recommended laboratory testing for CKD during the same 12 months. Using publicly available information for calendar year 2021, we estimated that of 39907 patients at the three institutions with stage 3 or stage 4 CKD documented by laboratory values only, 3937 (9.9%) would be enrolled in Medicare Advantage or Affordable Care Act Market programs. The imputed lost reimbursement under risk-adjusted payment systems for this under-documentation of CKD was $3.3M for the three institutions combined, representing lost opportunity for both identification and proactive clinical management of these patients, and financial recovery for the costs of providing that care. Conclusions: We conclude that clinical laboratories can provide value beyond routine diagnostics, for identification of gaps in care for identification and management of CKD, stratifying subgroups of patients to identify risk, and capturing missed reimbursement through risk adjustment factors not documented in the billing system.