Accuracy of Medicare Local Coverage Determination Guidelines for Chronic Renal Failure

Outcomes 1. Participants will self-report the ability to name LCD criteria for chronic renal failure.2. Participants will be able to evaluate the prognostic utility of LCD guidelines compared to receiving an expected six months of hospice care. Key Message Chronic renal failure (CRF) disproportionately impacts Black Americans. Our data demonstrate that Medicare criteria for hospice service eligibility at six months among patients with CRF has poor prognostic utility and patients experienced less than one month of hospice care, which may further racial disparities in healthcare delivery in this population. Introduction Chronic renal failure (CRF) is a leading cause of death in the United States impacting Black Americans at more than three times the rate of white Americans. [1] Medicare local coverage determination (LCD) criteria are designed to help identify patients eligible for hospice care. For CRF, these guidelines require that a patient is not seeking dialysis, renal transplant, or is discontinuing dialysis, and has a creatinine clearance (GFR) < 15ml/min or serum creatinine > 8.0 mg/dl. [2] Objective To determine whether LCD guidelines for hospice referrals due to CRF accurately identify patients with a six-month prognosis. Methods Nonparametric maximum likelihood survival analysis was used to assess the time period during which patients met LCD guidelines for CRF stratified by dialysis utilization. We included patients with CRF who met LCD guidelines at the time of death and utilized accountable care organization outpatient data from BJC HealthCare in Saint Louis from January 2017 to February 2020. Results 221 patients met LCD criteria for CRF at the time of death, of which 94 (42.5%) had dialysis services recorded while 127 (57.5%) did not. The probability of a patient meeting LCD criteria for at least one month was 0.21 (95% confidence interval [CI]: 0.15, 0.26), decreasing to 0.04 (95% CI: 0.01, 0.07) for at least six months. All patients experienced a median time of 7 days for meeting criteria compared to 12 days for patients who did not utilize dialysis. Conclusion LCD guidelines failed to accurately identify CRF patients with a six-month prognosis. The low sensitivity of the CRF LCD identified in this preliminary evaluation may lead to inappropriate denials of hospice eligibility and disproportionately reduce access to hospice care for Black Americans. A data-driven approach is needed to develop more equitable guidelines. Keywords Ethical / Legal Aspects of Care; Disease specific management