Quality of life and patient satisfaction: ESRD managed care demonstration

Health Care Financing Review, Summer, 2003 by Trinh B. Pifer, Jennifer L. Bragg-Gresham, Dawn M. Dykstra, Jennifer R. Shapiro, Caitlin Carroll Oppenheimer, Daniel S. Gaylin, Nancy Beronja, Robert J. Rubin, Philip J. Held

Quality of Life

Results from our quality of life analyses address a key evaluation question of the demonstration: Does enrollment in managed care rather than traditional (i.e., FFS) programs affect the quality of life experienced by ESRD patients? Quality of life measures are increasingly being recognized as important indicators of health, emphasizing the importance of the question.

The results presented here touch on several quality of life issues. First, these analyses assess whether or not baseline differences exist among those ESRD patients choosing to enroll in the demonstration as compared with a nationally representative sample of patients. Second, baseline quality of life was compared between managed care patients and the FFS and NDMC samples, which were matched on age, race, and time on ESRD. Differences between the first and second sets of comparisons can indicate differences in quality of life resulting from characteristics other than the ones matched for. Finally, our results explore changes in quality of life over time.

Quality of Life at Baseline

Results of the analyses comparing baseline quality of life of hemodialysis demonstration patients to that of DOPPS patients in California and Florida provide evidence that demonstration patients in these two States were healthier than a cross section of all hemodialysis patients in these service areas. At baseline, demonstration patients had higher physical and mental component summary scores. These differences were statistically significant at p<0.05, but they were not clinically meaningful as determined by the criterion of a [greater than or equal to] 3-point difference (Samsa et al., 1999; Hays and Woolley, 2000). Furthermore, adjusted results indicate that demographic and comorbidity factors (including age, sex, race, coronary artery disease, peripheral vascular disease, and hypertension) accounted for all of the difference in baseline quality of life scores.

Matched Comparisons

Baseline quality of life comparisons were also conducted to compare physical and mental component scores of demonstration patients with the matched FFS and NDMC samples. With the exception of the physical component score among the NDMC sample, there were no differences in quality of life scores between demonstration patients and the two matched comparison samples.

The higher physical component score among NDMC patients may indicate that patients who had been in managed care for some period of time (NDMC patients) were healthier and had better physical quality of life than patients who opted for managed care at baseline. However, since this difference does not appear to be clinically significant, further work would be necessary to determine whether there is indeed any benefit of MCPs over time.

Changes in Quality of Life

Longitudinal analyses that assess changes in quality of life and other health indicators over time are especially crucial for evaluating the success of managed care models for ESRD patients. The results showed some statistically and clinically significant changes in quality of life scores among demonstration patients between baseline and followup. Nearly every subscale of the physical and mental component scores either improved or stayed approximately the same after 1 year. For three of these subscales--bodily pain, mental health, and role-emotional--the improvement is statistically significant as well as clinically meaningful. The overall mental component score also showed a statistically significant increase. These results are striking because ESRD patients, due to the chronic nature of their illness, typically exhibit deteriorating quality of life over time. Indeed, when we examined a sample of DOPPS patients over a 1-year period of time, we observed a decrease in score among all of the subscale components as well as the two summary scores. Five of the scores (physical functioning, bodily pain, physical component score, social functioning, and vitality) showed statistically significant declines.