Gianna Melillo

 underscore the relationship between social determinants of health (SDOH) and chronic kidney disease (the 

) in military populations and the challenges of tracking these factors.

“A growing body of evidence suggests that negative SDOH—or social risks—contribute to socioeconomic and racial disparities in CKD,” researchers wrote.

 “One mechanism through which social risks appear to produce disease is by impeding access to healthcare.”

Using data from the Military Health System (MHS), researchers assessed CKD disparities in the context of universal health care. All MHS beneficiaries between the ages of 18 and 64 who received care from the MHS from October 2015 through September 2018 were included in the analysis. 

International Classification of Disease, 10th Revision 

(ICD-10), codes and/or validated laboratory value-based electronic phenotypes constituted CKD incidence.

The investigators used multivariable logistic regression models to compare the prevalence of CKD by race, rank, and other factors while controlling separately for confounders.

A total of 3,330,893 beneficiaries were included in the analysis, of whom 105,504 (3.2%) had CKD. Confounder-adjusted models showed, “CKD prevalence was statistically elevated in beneficiaries of Black vs White race, lower vs higher rank (as a proxy for socioeconomic status), lower vs higher income, and married vs single status (

However, associations were mitigated when adjusting for suspected mediators, “indicating the mediators may indeed be on the causal pathway between social risks and CKD,” the researchers wrote. The findings also suggest social factors remain pertinent despite access to universal health care coverage.

 investigators found low documentation of SDOH among US veterans and Medicare patients with CKD. In 2015, implementation of 

 codes included new Z-codes to specifically identify SDOH. In this investigation, the researchers “sought to identify differences in SDOH-related Z-code (SDOH-ZC) utilization in Veterans Health Administration and Medicare patients, identifying differences in SDOH-ZC utilization in those with and without CKD.”

The study included a 5% sample of Medicare claims data from 2015 to 2018 and 100% of VA health data amassed during the same time period. SDOH-ZCs were grouped into 17 categories such as employment status, housing, and economic circumstances.

The researchers measured the proportion of claims assigned a SDOH-ZC quarterly across different health care encounters and described by patient demographic and medical characteristics. Code use was then compared between those with CKD and those without.

SDOH-ZCs appeared more frequently in the VA health system than in Medicare data

Tobacco use was the most common SDOH-ZC in both the Medicare and VA data

More SDOH-ZCs were evident in the VA employment, environment, housing and economic, and family circumstances

Compared to those without CKD, use of SDOH-ZC was higher in individuals with CKD in outpatient settings but lower among those with inpatient visits, observation stays, and emergency department visits

“We observed lower recording of SDOH overall and among those with CKD in health care settings,” the authors concluded. “Additional efforts might consider increasing SDOH documentation to help assess need for social services, which could potentially reduce disparities in health outcomes by socioeconomic status.”

Norton JM, Grunwald L, Olsen CH, Marks ES, and Koehlmoos TL. Social determinants of CKD in the military health system. Presented at: Kidney Week; October 22-25, 2020. Abstract PO0474

Han Y, Yin M, Steffick D, et al. Low documentation of social determinants of health among US veterans and Medicare patients with CKD. Presented at: Kidney Week; October 22-25, 2020. Abstract PO0475

Articles

A pair of abstracts presented at Kidney Week 2020 underscore the relationship between social determinants of health (SDOH) and chronic kidney disease (CKD) in military populations and the challenges of tracking these factors. 

Research Highlights Impact of SDOH on Veterans With CKD

This week, CMS proposed changes to the Medicare Durable Medical Equipment Prosthetics, Orthic Devices and Supplies (DMEPOS) coverage and payment policies which would expand Medicare coverage for continuous glucose monitors (CGMs).

 over whether Medicare would cover CGMs for beneficiaries, one-third of whom currently have 

The new proposed rule would “expand the interpretation regarding when external infusion pumps are appropriate for use in the home and can be covered as DME under Medicare Part B,” according to a CMS 

. The change would also reduce administrative burdens resulting from government coverage, payment, and coding processes that can hinder innovators from getting products to beneficiaries.

If finalized, the rule would classify all CGMs as DME and establish payment amounts for the items and related supplies.

, the FreeStyle Libre 2 CGM, manufactured by Abbott, became available to Medicare patients who meet certain eligibility coverage criteria, following an April FDA authorization for the device’s use in hospitalized patients with coronavirus disease 2019 (COVID-19).

“We are very encouraged by CMS’s proposed rule and commend the agency on taking action to help more people with diabetes,” said Sean Salmon, executive vice present and president of the Diabetes Group at Medtronic.

“We strongly believe this proposal puts patients first and empowers them to choose the therapies that best meet their diabetes management needs. Importantly, the proposed rule would enable continuity of therapy for people on Medtronic insulin pumps aging into Medicare — including Medtronic hybrid closed loop systems which automatically adjust insulin delivery based on readings from the integrated CGM. We look forward to continuing to engage with CMS and other stakeholders in the finalization of this important rule.”

 from the Association of Diabetes Care & Education Specialists (ADCES) found individuals living with diabetes feel they are doing everything they can to manage the condition yet believe more can be done.

Of individuals who currently track their blood glucose levels with a blood glucose monitor or continuous glucose monitor, 47% reported their current method is simple and easy, but they also wish it was even more simple and easy to do.

“With the policies outlined in this proposed rule, innovators have a much more predictable path to understanding the kinds of products that Medicare will pay for,” said CMS Administrator Seema Verma. “For manufacturers, bringing a new product to market will mean they can get a Medicare payment amount and billing code right off the bat, resulting in quicker access for Medicare beneficiaries to the latest technological advances and the most, cutting-edge devices available.”

CMS only currently covers therapeutic CGMs or those approved by the FDA for use in making diabetes treatment decisions, like changing one’s diet or insulin dosage based solely on the readings of the CGM.

The rule would also expand classification of external infusion pumps under the DME in cases where assistance from a home infusion therapy supplier is necessary.

As part of the changes, the agency will continue to pay higher amounts to suppliers of DMEPOS items and services in rural and non-contiguous areas of the United States, based on stakeholder feedback indicating unique challenges and higher costs in these regions.

This week, CMS proposed changes to the Medicare Durable Medical Equipment Prosthetics, Orthic Devices and Supplies (DMEPOS) coverage and payment policies which would expand Medicare coverage for continuous glucose monitors (CGMs). 

CMS Proposes New Rules for CGM Coverage Among Medicare Beneficiaries

Results from a prespecified ancillary study show neither vitamin D3 nor marine ω-3 fatty acid supplementation had a significant overall effect on age-related macular degeneration (AMD) incidence or progression. 

AMD is the leading cause of severe, irreversible 

 in US adults while for those with advanced, neovascular AMD, treatment is currently available in the form of anti-vascular endothelial growth factor therapy. For individuals with intermediate to advanced forms of the disease, supplements of antioxidants plus zinc is recommended.

Thus, “for the large majority of people with early or no AMD, there is no effective intervention other than lifestyle modifications, such as avoidance of cigarette smoking,” authors wrote.

Previous observational studies have suggested higher intake or blood levels of vitamin D and marine ω-3 fatty acids may be associated with lower risks of the disease.

In the current study, researchers analyzed data from the Vitamin D and Omega-3 Trial (VITAL), a double-blind, placebo-controlled randomized clinical trial initially designed to analyze the supplements’ association with prevention of cancer and cardiovascular disease among US men and women.

Between November 2011 and March 2014, a total of 25,871 participants with a mean (SD) age of 67.1 (7) years were randomized to receive 2000 IU of vitamin D3 (cholecalciferol) or 1 g of marine ω-3 fatty acids per day. Pill taking ended on December 31, 2017, yielding a median (range) treatment window of 5.3 (3.8-6.1) years.

At baseline, each participant completed a questionnaire asking if they had ever been diagnosed with macular degeneration. Subsequent annual questionnaires also included the question. Following an affirmative answer, “ophthalmologists and optometrists were contacted by mail and asked to complete an AMD questionnaire that requested information on the date of initial diagnosis, best-corrected visual acuity at the time of diagnosis, and date when best-corrected visual acuity reached 20/30 or worse.”

Some participants also gave annual blood samples which showed a mean rise of 40% in vitamin D level and 54.7% in ω-3 level over the course of the trial.

The final study cohort included 71.3% non-Hispanic White participants and 20.2% Black participants. Analyses revealed:

324 participants experienced an AMD event (285 incident AMD and 39 progression to advanced AMD)

For vitamin D3, there were 163 events in the treated group and 161 in the placebo group (hazard ratio [HR], 1.02; 95% CI, 0.82-1.27)

For ω-3 fatty acids, there were 157 events in the treated group and 167 in the placebo group (HR, 0.94; 95% CI, 0.76-1.17)

HRs comparing vitamin D3 groups were 1.09 (95% CI, 0.86-1.37) for incident AMD and 0.63 (95% CI, 0.33-1.21) for AMD progression

For ω-3 fatty acids, HRs were 0.93 (95% CI, 0.73-1.17) for incident AMD and 1.05 (95% CI, 0.56-1.97) for AMD progression

Average rate of response to study questionaries was 93.1% and adherence to the pill regimen was high, as more than 80% of participants reported taking at least two-thirds of the capsules during the 5 years of follow-up.

Because the AMD end point was based on participant reports followed by medical record review, researchers noted some underascertainment of AMD is likely.

“These negative results of a large, well-designed, and well conducted clinical trial, performed by highly experienced investigators, is discouraging,” wrote Robert N. Frank, MD, in an accompanying 

 He continued, “although the present study yielded negative results, it has been abundantly clear over the last number of years that overall progress in other areas of research in the causes and treatment of AMD remains considerable.”

Christen WG, Cook NR, Manson JE, et al. Effect of vitamin D and ω-3 fatty acid supplementation on risk of age-related macular degeneration. 

. Published online October 29, 2020. doi: 10.1001/jamaophthalmol.2020.4409

Frank, RN. Of age-related macular degeneration and vitamins. 

. Published online October 29, 2020. doi:10.1001/jamaophthalmol.2020.4417

Vitamin D, Marine ω-3 Fatty Acid Supplementations Have No Impact on AMD 

 CONVERGE Virtual Conference, experts discussed the role social determinants of health (SDOH) play in community-based health initiatives and how the coronavirus disease 2019 (COVID-19) pandemic has spurred partnerships across the continuum of care to optimize health outcomes.

Defining health as social, behavioral, and physical well-being, panelists offered insights on crises the pandemic has wrought on communities and future steps to take for improvement. Specifically, the conference focused on initiatives spanning Albany, Rensselaer, Schenectady, Fulton, Montgomery, and Saratoga counties in New York state.

“The pandemic is exacerbating the food access and resource problems we already knew existed,” said Natasha Pernicka, the executive director of the Food Pantries for the Capital District. “Our food access referral line saw an increase of service of 1000% when the COVID-19 shutdown happened in the spring, and we’re continuing to see high increases in people seeking assistance.”

A lack of access to nutritious food on a consistent basis can affect chronic conditions like diabetes, heart disease, and hypertension; malnutrition in general is an underrecognized issue in the United States. Roughly half of hospitalized patients in the country are either malnourished or at risk of malnourishment, and only 8% of those patients receive a diagnosis of malnutrition while in the hospital, Pernicka explained.

To avoid future hospital administration costs and to enhance the healing process in high-risk patients, improved access to community-based nutrition resources is critical.

Elaborating on the problem of food instability, Peter Gannon, the president and CEO of United Way of the Greater Capital Region, noted than when children gain weight throughout the year, 50% of the weight gained is during the summer months, due largely to lack of access to nutritious food.

Once the pandemic is over, children will be returning to the school setting with physical health issues “that we may not be able to determine into their 20s, 30s, or even much later in their lives, as well as the impacts of mental health issues,” Gannon said.

Compounding the challenges, many of the nonprofit organizations working to improve conditions at the local level may not be able to endure the financial fallout of the pandemic. “We could lose 30% to 40% of 501c3s over the next couple of years,” Gannon said. “Yes, the safety net was in place this time, but…if something happens 2 years from now or 5 years from now, there’s going to be a disruption.”

However, the pandemic has also brought cross-sector collaboration like we have never seen before, Pernicka said, which can help alleviate roadblocks to resources and services. “We have community based-organizations, private businesses, health care, and government coming together to create programs that increase access, and we're hoping that this will continue.”

Importantly, awareness of these issues has been established, while institutions equipped to address the issues are already in place. “We know what works, we just need to direct resources in that direction,” Pernicka concluded, highlighting a major theme of the conference.

In addition to food insecurity, panelists also brought up the issue of housing instability. “When we think about what we need to do to create healthy equitable communities, I think we have to start by first acknowledging that all of us bring biases and emotions to the table when we talk about poverty,” said Kathy Sheehan, the mayor of Albany, New York.

To highlight the harmful impact of housing policies, Sheehan compared the system in place to that of Medicare. Currently, individuals who qualify for housing are unable to obtain it because there is not enough funding to provide all those eligible with housing.

“We don’t do that with Medicare, for example. When you turn 65, we don’t say, ‘Sorry we’re full, you have to wait for somebody who is in their 80s to pass away and then we’ll make a slot for you.’ We provide that health care,” Sheehan said. “If you qualify for Supplemental Nutrition Assistance Program (SNAP) benefits, you receive those benefits. But if you qualify for housing, which to me is one of the most fundamental underlying needs if you want to start to focus on health and healthy community, we make people wait in line sometimes for decades.”

Ultimately, these inefficient systems like those governing housing policies drive up health care costs in the long run. In 2020, Sheehan emphasized governments and health systems have access to the technology and data that can help individuals at the micro, block-by-block level. Improving systems, utilizing data, and including those who are most affected by the inequities in discussions on solutions are integral steps to a collaborative approach in improving outcomes.

One way of implementing these steps is through the Collaborative Approach to Public Good Investments or CAPGI, presented by Len Nichols, MA, PhD, the Director of the Center for Health Policy Research and Ethics and professor of Health Policy at George Mason University.

, was designed as a tool for communities to achieve their common will via multistakeholder coalition investments in SDOH like housing, food, and transportation.

“Those services directed to specific individuals in a timely fashion can lower costs and improve the mission congruent values of organizations of various types, including hospitals, insurers and city hall,” Nichols said. Investments in these services for individuals with specific social needs generate benefits for a wide array of individuals downstream, leading to “an economics of public good.”

In particular, CAPGI solves the problem that exists when people could benefit from others’ investments and therefore tend to underinvest, or the so-called “free rider” problem.

“There is no place in the country that has enough investment upstream to the health care system,” Nichols said. In order for CAPGI to work, there must be a functional operational events local stakeholder coalition, and a trusted broker, or someone trusted by the individual stakeholders enough that they are willing to share what they will pay to solve the problem. “The trusted broker then adds up those confidential bids and assesses if we have enough economic value here to justify the project.”

And, because of hospital readmission penalties, Medicaid expansion (thus, more homeless individuals on the rolls of insurance plans), and the opioid crisis, these 2 conditions are already present in many communities throughout the country. Community level coalitions spurred by these events look upstream together for solutions, Nichols explained.

“Our framework is: You reveal the willingness to pay to the trusted broker only, the trusted broker adds up the values, they assign the bids, and then can assign prices so that the surplus, the excess of value over cost, is fairly shared. And it is that surplus being shared and the return on investment that’s baked into the pricing structure that creates a self-interest that will drive the model to sustainability over time.”

Fairness constraints—no one ever paying more than they bid, everyone sharing a surplus, and each stakeholder sharing in the surplus in equal proportion—ensure that the system is beneficial and sustainable.

Thus far, 10 communities are poised to enact the model on a local level, and although communities may list the same SDOH as the most important upstream problems, the level of urgency among the communities differs. “I think that sometimes a sense of urgency can crystallize and catalyze a movement, and that’s kind of what we’re trying to do, to enable that to happen,” Nichols concluded.

At the Alliance for Better Health’s CONVERGE Virtual Conference, experts discussed the role social determinants of health (SDOH) play in community-based health initiatives. 

Author | Gianna Melillo

Articles

Research Highlights Impact of SDOH on Veterans With CKD

CMS Proposes New Rules for CGM Coverage Among Medicare Beneficiaries

Vitamin D, Marine ω-3 Fatty Acid Supplementations Have No Impact on AMD

Panelists Discuss Community-Based Approaches to Mitigate Costs, Improve SDOH Outcomes