Title: Atlantis Healthcare Chronic Disease Management Program

Author: Trevon Morales, Rubette Harford, Dulcie Kermah, Jose Flaque, Michelle Camacho, Damaris Vasquez, Inés Hernández, James P. O’Drobinak, Keith Norris.

Area of concentration: Global Health

Keywords: Chronic kidney disease (CKD), Diabetes (DM), Pre-diabetes

Background: Chronic kidney disease (CKD) disproportionately affects older adults and individuals with comorbid diabetes and hypertension. Despite its high burden, CKD remains underdiagnosed, particularly in minority populations, and Puerto Rican patients are notably underrepresented in national CKD research. In Puerto Rico, Medicare Advantage (MA) is the primary coverage model, yet its structure—limiting dialysis coverage to only three months before transitioning to traditional Medicare—results in lower physician reimbursement, limited specialist availability, and higher out-of-pocket costs for patients.

Objective: To evaluate disease progression, stability, and regression among older Puerto Rican patients enrolled in a Chronic Disease Management (CDM) program for CKD and to contextualize these findings within broader disparities in CKD care access and outcomes.

Methods: A retrospective analysis of 7,293 Puerto Rican patients with CKD enrolled in a CDM program as of September 30, 2024. Of these, 4,362 received nephrologist evaluation and 4,111 had complete longitudinal data across up to three time points. CKD stages were tracked to assess maintenance, progression, or regression over time.

Results: The majority of patients were aged 65–84 years and presented with Stage 2 (44%) or Stage 3 (27%) CKD at enrollment. Among Stage 2 patients, 70% maintained their stage, 15% improved to Stage 1, and 15% progressed to Stage 3. Similarly, 72% of Stage 3 patients remained stable, 22% regressed to a lower stage, and only 7% progressed to Stage 4/5. These findings demonstrate that with structured management, CKD progression is not inevitable and regression is possible, even among older adults in underserved populations.

Conclusion: This study highlights the impact of a targeted CDM program in stabilizing or reversing CKD in Puerto Rican patients—a population frequently overlooked in CKD literature. It also underscores the need for Medicare policy reform and tailored research that addresses the structural inequities and unique challenges faced by patients and providers in Puerto Rico