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Chen YC, Weng SF, Hsu YJ, Wei CJ, Chiu CH. Continuity of care: evaluating a multidisciplinary care model for people with early CKD via a nationwide population-based longitudinal study. BMJ Open 2020; 10:e041149. [PMID: 33376170 PMCID: PMC7778764 DOI: 10.1136/bmjopen-2020-041149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES To control and prevent the burdens associated with chronic kidney disease (CKD), Taiwan's National Health Insurance Administration (NHIA) launched the 'early-CKD programme' in 2011 to extend care and education to patients with CKD. This study aims to evaluate the effectiveness of the early-CKD programme in terms of continuity of care (COC). DESIGN AND PARTICIPANTS This study used secondary data from 2010 to 2014 provided by the NHIA to identify 86 581 participants each for the intervention and control groups. Patients with CKD who participated in the early-CKD programme between 2011 and 2013 were defined as the intervention group. For the control group, propensity score matching was used to select patients with CKD who did not participate in the programme, but were seen by the same group of physicians. INTERVENTION A multidisciplinary care model for patients with early CKD launched in 2011. PRIMARY OUTCOME MEASURES Outcome variables included the continuity of care index (COCI), which measures a physician's COC; number of essential examinations; and resource utilisation. To better identify the difference between groups, we separated COCI into two groups based on mean: high (above mean) and low (below mean). A generalised estimating equation model was used to examine the effects of the early-CKD programme. RESULTS The programme significantly increased the number of essential examinations/tests administered to patients (β=0.61, p<0.001) and improved COCI between physicians and patients (OR=4.18, p<0.001). Medical expenses (β=1.03, p<0.001) and medication expenses (β=0.23, p<0.001) significantly increased after the programme was implemented, but patients' kidney-related hospitalisations and emergency department visits decreased (β=-0.13, p<0.001). CONCLUSION From the COC viewpoint, the programme in Taiwan showed a positive effect on COCI, number of essential examinations and resource utilisation.
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Affiliation(s)
- Yin-Cheng Chen
- Division of Nephrology, Department of Internal Medicine, Taipei Hospital, Ministry of Health and Welfare, Taipei, Taiwan
| | - Shuen-Fu Weng
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yu-Juei Hsu
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chung-Jen Wei
- Department of Public Health, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Chiung-Hsuan Chiu
- School of Health Care Administration, Taipei Medical University, Taipei, Taiwan
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Implementation of Cluster-Based Management Strategies for Patients With Chronic Kidney Disease. J Nurse Pract 2020. [DOI: 10.1016/j.nurpra.2020.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Healthcare professionals' perceptions of the role of a multidisciplinary approach in improving the care of patients with advanced chronic kidney disease. Int Urol Nephrol 2020; 52:2357-2365. [PMID: 32740786 DOI: 10.1007/s11255-020-02571-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/07/2020] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To explore and understand the experiences of healthcare professionals (HCPs) delivering care in a multidisciplinary care (MDC) clinic for advanced chronic kidney disease (CKD) patients. METHODS This is a qualitative study based on semi-quantitative questionnaire and semi-structured interviews with thematic analysis and deductive mapping onto the Theoretical Framework of Acceptability. Sixteen HCPs caring for advanced CKD patients in a MDC clinic in a tertiary teaching hospital in Singapore were recruited based on maximum variation sampling procedures. RESULTS The majority of the HCPs were supportive of a MDC clinic. There was a positive overall opinion of the programme [median 7.0 of 10.0 (IQR 7.0-8.0)], high satisfaction ratings for interaction with other members of team [6.9 (5.3-8.0)] and time spent with patients [7.0 (5.3-7.0)]. Thematic analysis of the interviews identified the value of MDC clinic in the provision of one-stop care, the improvement in communication and collaboration between HCPs, the facilitation of patient activation to make planned kidney care decisions, and the optimisation of medications. The main challenges were lack of continuity of care, manpower constraints, poor patient navigation between HCPs, poor patient attendance with allied HCPs, and the perception of increased cost and time spent by patients in each MDC clinic visit. The proposed interventions were notification of patients beforehand of the MDC clinic schedule and provision of navigation to patients within the MDC clinic. CONCLUSION A multidisciplinary care clinic for advanced chronic kidney disease patients was viewed positively by the majority of the healthcare professionals, with areas for improvement.
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Piccoli GB. Who should be responsible for the care of advanced chronic kidney disease? Do the guidelines point to the end of nephrology follow-up of advanced CKD or are they the starting point for a new approach? BMC Nephrol 2020; 21:309. [PMID: 32727392 PMCID: PMC7389685 DOI: 10.1186/s12882-020-01908-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 06/24/2020] [Indexed: 01/19/2023] Open
Abstract
The editorial comments on a recently published study in which 242 patients, with “stable” chronic kidney disease, recruited during a hospital stay, were randomised either to receiving support from nephrologists (co-management by primary care physicians and nephrologists), or to be managed by primary care physicians with written instructions and nephrology consultations on demand. After a mean follow-up of 4 years, the results in terms of dialysis start, hospitalisation and death were similar for both groups. This study gave the possibility to discuss about the options of follow-up of CKD patients, including on one side the advantage of a greater involvement of primary care physicians, who could oversee care by applying a common set of simplified guidelines, and on the other one the importance of a direct and deep involvement of the specialists that seems necessary in particular if personalised approaches have to be pursuit. The data of the present study are somehow in disagreement with the literature, usually suggesting better outcomes in intensive treatment, in which specialists are directly involved. The literature is heterogeneous, the goals vary and the populations are differently selected. The compliance issue is probably one of the missing pieces of the puzzle, and specific interventions should also be tailored to “reluctant” patients. Guidelines should probably be staring points for improvement, and not the standard of care; the study herein discussed may suggest that primary care physicians may be of great help in granting a good standard of care, hopefully as a baseline for further improvement, and personalised care.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, University of Torino, 10124, Torino, Italy. .,Nephrologie, Centre Hospitalier Le Mans, 72037, Le Mans, France.
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Songsermlosakul S, Permsuwan U, Singhan W. Treatment Costs for Patients with Chronic Kidney Disease Who Received Multidisciplinary Care in a District Hospital in Thailand. CLINICOECONOMICS AND OUTCOMES RESEARCH 2020; 12:223-231. [PMID: 32425563 PMCID: PMC7196240 DOI: 10.2147/ceor.s253252] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 04/08/2020] [Indexed: 12/24/2022] Open
Abstract
Aim To estimate direct medical treatment costs in patients with pre-dialysis chronic kidney disease (CKD) in a district hospital and to analyze the factors that affected the treatment costs. Patients and Methods Data were retrospectively retrieved from the hospital database in the period from January 2015 to December 2017. Patients who were diagnosed with CKD and had visited ambulatory care services at least two times during the index year (January to December 2015) were included. Patients' data were excluded if they had cancer, had received renal replacement therapy, or had been referred to receive treatment at other hospitals. Treatment costs based on the providers' perspectives in the first and second years after the index year were assessed. Descriptive statistics were used to analyze patients' characteristics, and multiple linear regression was used to analyze the factors in the cost model. Results Data of 212 patients with CKD stage G3a, G3b, or G4 who met inclusion and exclusion criteria were included for analysis. Average costs for treatment in year 1 and year 2 were not statistically different. Total cost was 5701.34 Thai Baht (THB) per year. The total cost for patients with CKD stage G4 was two times greater than for patients with CKD stage G3. Costs were increased for longer hospitalization, more frequent ambulatory visits, having diabetes mellitus or dyslipidemia as a comorbidity, and uncontrolled fasting blood glucose (FBG). A cost model with R 2=0.906 was provided. Significant predictors were length of stay, ambulatory visits, diabetes mellitus, dyslipidemia, serum creatinine, FBG, and body mass index. Conclusion Total annual treatment costs for the 2 years were not different. A more advanced stage of CKD, having diabetes mellitus or dyslipidemia as comorbidities, and uncontrolled FBG were significantly associated with increased costs for treatment in patients with pre-dialysis CKD.
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Affiliation(s)
| | | | - Wanchana Singhan
- Faculty of Pharmacy, Chiang Mai University, Chiang Mai, 50200, Thailand
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Abstract
People with advanced chronic kidney disease and evidence of progression have a high risk of renal replacement therapy. Specialized transition clinics could offer a better option for preparing these patients for dialysis, transplantation or conservative care. This review focuses on the different aspects of such transition clinics. We discuss which patients should be referred to these units and when referral should take place. Patient involvement in the decision-making process is important and requires unbiased patient education. There are many themes, both patient-centred and within the healthcare structure, that will influence the process of shared decision-making and the modality choice. Aspects of placing an access for haemodialysis and peritoneal dialysis are reviewed. Finally, we discuss the importance of pre-emptive transplantation and a planned dialysis start, all with a focus on multidisciplinary collaboration at the transition clinic.
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Affiliation(s)
- Marie Evans
- Renal Unit, Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Kai Lopau
- Department of Internal Medicine , University of Würzburg, Würzburg, Germany
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Collister D, Pyne L, Cunningham J, Donald M, Molnar A, Beaulieu M, Levin A, Brimble KS. Multidisciplinary Chronic Kidney Disease Clinic Practices: A Scoping Review. Can J Kidney Health Dis 2019; 6:2054358119882667. [PMID: 31666978 PMCID: PMC6801876 DOI: 10.1177/2054358119882667] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 08/27/2019] [Indexed: 12/25/2022] Open
Abstract
Background: Multidisciplinary chronic kidney disease (CKD) clinics improve patient
outcomes but their optimal design is unclear. Objective: To perform a scoping review to identify and describe current practices
(structure, function) associated with multidisciplinary CKD clinics. Design: Scoping review. Setting: Databases included Medline, EMBASE, Cochrane, and CINAHL. Patients: Patients followed in multidisciplinary CKD clinics globally. Measurements: Multidisciplinary CKD clinic composition, entry criteria, follow-up, and
outcomes. Methods: We systematically searched the literature to identify randomized controlled
trials, non-randomized interventional studies, or observational studies of
multidisciplinary CKD clinics defined by an outpatient setting where two or
more allied health members (with or without a nephrologist) provided
longitudinal care to 50 or more adult or pediatric patients with CKD.
Included studies were from 2002 to present. Searches were completed on
August 10, 2018. Title, abstracts, and full texts were screened
independently by two reviewers with disagreements resolved by a third. We
abstracted data from included studies to summarize multidisciplinary CKD
clinic team composition, entry criteria, follow-up, and processes. Results: 40 studies (8 randomized controlled trials and 32 non-randomized
interventional studies or observational studies) involving 23 230
individuals receiving multidisciplinary CKD care in 12 countries were
included. Thirty-eight focused on adults (27 with CKD, 10 incident dialysis
patients, one conservative therapy) while two studies focused on adolescents
or children with CKD. The multidisciplinary team included a mean of 4.6 (SD
1.5) members consisting of a nephrologist, nurse, dietician, social worker,
and pharmacist in 97.4%, 86.8%, 84.2%, 57.9%, and 42.1% of studies
respectively. Entry criteria to multidisciplinary CKD clinics ranged from
glomerular filtration rates of 20 to 70 mL/min/1.73m2 or CKD
stages 1 to 5 without any proteinuria or risk equation-based criteria.
Frequency of follow-up was variable by severity of kidney disease. Team
member roles and standardized operating procedures were infrequently
reported. Limitations: Unstandardized definition of multidisciplinary CKD care, studies limited to
CKD defined by glomerular filtration rate, and lack of representation from
countries other than Canada, Taiwan, the United States, and the United
Kingdom. Conclusions: There is heterogeneity in multidisciplinary CKD team composition, entry
criteria, follow-up, and processes with inadequate reporting of this complex
intervention. Additional research is needed to determine the best model for
multidisciplinary CKD clinics. Trial registration: Not applicable.
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Affiliation(s)
- David Collister
- St. Joseph's Healthcare Hamilton, ON, Canada.,Ontario Renal Network, Toronto, Canada
| | - Lonnie Pyne
- St. Joseph's Healthcare Hamilton, ON, Canada
| | | | | | - Amber Molnar
- St. Joseph's Healthcare Hamilton, ON, Canada.,Ontario Renal Network, Toronto, Canada
| | - Monica Beaulieu
- British Columbia Renal Agency, Vancouver, Canada.,The University of British Columbia, Vancouver, Canada
| | - Adeera Levin
- British Columbia Renal Agency, Vancouver, Canada.,The University of British Columbia, Vancouver, Canada
| | - K Scott Brimble
- St. Joseph's Healthcare Hamilton, ON, Canada.,Ontario Renal Network, Toronto, Canada
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Awdishu L, Moore T, Morrison M, Turner C, Trzebinska D. A Primer on Quality Assurance and Performance Improvement for Interprofessional Chronic Kidney Disease Care: A Path to Joint Commission Certification. PHARMACY 2019; 7:pharmacy7030083. [PMID: 31277293 PMCID: PMC6789732 DOI: 10.3390/pharmacy7030083] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 06/19/2019] [Accepted: 06/27/2019] [Indexed: 01/23/2023] Open
Abstract
Interprofessional care for chronic kidney disease facilitates the delivery of high quality, comprehensive care to a complex, at-risk population. Interprofessional care is resource intensive and requires a value proposition. Joint Commission certification is a voluntary process that improves patient outcomes, provides external validity to hospital administration and enhances visibility to patients and referring providers. This is a single-center, retrospective study describing quality assurance and performance improvement in chronic kidney disease, Joint Commission certification and quality outcomes. A total of 440 patients were included in the analysis. Thirteen quality indicators consisting of clinical and process of care indicators were developed and measured for a period of two years from 2009–2017. Significant improvements or at least persistently high performance were noted for key quality indicators such as blood pressure control (85%), estimation of cardiovascular risk (100%), measurement of hemoglobin A1c (98%), vaccination (93%), referrals for vascular access and transplantation (100%), placement of permanent dialysis access (61%), discussion of advanced directives (94%), online patient education (71%) and completion of office visit documentation (100%). High patient satisfaction scores (94–96%) are consistent with excellent quality of care provided.
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Affiliation(s)
- Linda Awdishu
- School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, CA 92093, USA.
- Nephrology Department, School of Medicine, University of California, San Diego, CA 92093, USA.
| | - Teri Moore
- Nephrology Department, School of Medicine, University of California, San Diego, CA 92093, USA
| | - Michelle Morrison
- Nephrology Department, School of Medicine, University of California, San Diego, CA 92093, USA
| | - Christy Turner
- Nephrology Department, School of Medicine, University of California, San Diego, CA 92093, USA
| | - Danuta Trzebinska
- Nephrology Department, School of Medicine, University of California, San Diego, CA 92093, USA
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Mirmiran R, Bush T, Cerra MM, Grambart S, Kauschinger E, Younger M, Zychowicz M. Joint Clinical Consensus Statement of the American College of Foot and Ankle Surgeons® and the American Association of Nurse Practitioners®: Etiology, Diagnosis, and Treatment Consensus for Gouty Arthritis of the Foot and Ankle. J Foot Ankle Surg 2019; 57:1207-1217. [PMID: 30368431 DOI: 10.1053/j.jfas.2018.08.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Gout is a condition that commonly affects the foot and ankle, and practitioners who treat these structures should be aware of the methods to diagnose and treat this form of arthritis. Practitioners also need to recognize extra-articular manifestations of the disease. Although the acutely red, hot, swollen joint is a common presentation, chronic tophaceous gout can be associated with pain, nodule formation, and cutaneous compromise. Since the underlying causes that lead to excessive monosodium urate deposition may be treatable, early and accurate diagnosis can be very beneficial and may even prevent articular degeneration.
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Affiliation(s)
- Roya Mirmiran
- Foot and Ankle Surgeon, Department of Surgery, Sutter Medical Group, Sacramento, CA.
| | - Tom Bush
- Associate Professor and Assistant Dean for Practice, University of North Carolina at Chapel Hill Schools of Nursing and Medicine, Chapel Hill, NC
| | - Michele M Cerra
- Director of the Duke NP/PA Rheumatology Fellowship Program & Faculty, Department of Medicine, Duke University School of Medicine, NC
| | - Sean Grambart
- Foot and Ankle Surgeon, Carle Physician Group, Department of Surgery, Champaign, IL
| | - Elaine Kauschinger
- Clinical Assistant Professor, Duke University School of Nursing, Durham, NC
| | - Melissa Younger
- Podiatric Research Fellow, Penn Presbyterian Medical Center, Philadelphia, PA
| | - Michael Zychowicz
- Professor and Director of MSN Program & Lead Faculty in Orthopedic NP Specialty, Duke University School of Nursing, Durham, NC
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Mirmiran R, Bush T, Cerra MM, Grambart S, Kauschinger E, Younger M, Zychowicz M. Joint Clinical Consensus Statement of the American College of Foot and Ankle Surgeons® and the American Association of Nurse Practitioners™: Etiology, Diagnosis, and Treatment Consensus for Gouty Arthritis of the Foot and Ankle. J Nurse Pract 2018. [DOI: 10.1016/j.nurpra.2018.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Machida S, Shibagaki Y, Sakurada T. An inpatient educational program for chronic kidney disease. Clin Exp Nephrol 2018; 23:493-500. [PMID: 30341571 DOI: 10.1007/s10157-018-1660-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 10/08/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) is a significant health problem in Japan, and prevention programs to slow disease progression are necessary. In this study, we evaluated the effectiveness of a 1-week inpatient education program, delivered during the predialysis stage of CKD, in slowing the deterioration in renal function over the subsequent 2 years, and identified factors influencing the program's effectiveness. METHODS We retrospectively evaluated the estimated glomerular filtration rate (eGFR) of 105 consecutive patients who completed the program, at the following time points: 6 months prior to program initiation, at program initiation and, at 6, 12, 18, and 24 months after the program. To identify factors predictive of program effectiveness, we classified patients into a Responder and Non-responder group. RESULTS In comparison with the rate of deterioration in renal function (mL/min/1.73 m2/year) before admission, the rate slowed at 6, 12, 18 and 24 months after discharge (all p < 0.01). A urinary protein (UP) level <0.5 g/gCr and CKD stages 4-5 were predictive of a slowing of CKD progression after the education program. CONCLUSIONS Although the effectiveness of our program declined over time, it did produce an overall slowing in the rate of renal function deterioration over the 2-year period of observation after discharge. This slowing of CKD progression was more pronounced in patients with low UP levels, indicating that education programs should be considered while these levels are still low. Furthermore, the program still offers benefits to patients with CKD stages 4-5.
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Affiliation(s)
- Shinji Machida
- Department of Nephrology and Hypertension, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, Japan
| | - Yugo Shibagaki
- Department of Nephrology and Hypertension, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, Japan
| | - Tsutomu Sakurada
- Department of Nephrology and Hypertension, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, Japan.
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Usefulness of multidisciplinary care to prevent worsening renal function in chronic kidney disease. Clin Exp Nephrol 2018; 23:484-492. [PMID: 30341572 DOI: 10.1007/s10157-018-1658-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 10/06/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Comprehensive education about lifestyle, nutrition, medications and other types of treatment is important to prevent renal dysfunction in patients with chronic kidney disease (CKD). However, the effectiveness of multidisciplinary care on CKD progression has not been evaluated in detail. We aimed to determine whether multidisciplinary care at our hospital could help prevent worsening renal function associated with CKD. METHODS A total of 150 pre-dialysis CKD outpatients accompanied (n = 68) or not (n = 82) with diabetes mellitus (DM) were enrolled into this study. We assessed annual decreases in estimated glomerular filtration rates (ΔeGFR), and measured systolic blood pressure (SBP), diastolic blood pressure (DBP), hemoglobin (Hb), uric acid (UA), low-density lipoprotein cholesterol (LDL), hemoglobin A1c (HbA1c) values and urinary protein to creatinine ratios (UPCR) 12 months before and after multidisciplinary care. In addition, changes in the number of medications and prescription ratio before and after multidisciplinary care were assessed in 90 patients with CKD who could confirm their prescribed medications. RESULTS The ΔeGFR significantly improved between before and after multidisciplinary care from - 5.46 to - 0.56 mL/min/1.73 m2/year, respectively. The number of medications and prescription ratio showed no significant changes before and after multidisciplinary care. The ratios of improved ΔeGFR were found in 66.7% of all patients, comprising 63.1% of males and 76.9% of females, 64.8% without DM and 69.4% with DM. Values for UA, LDL, and HbA1c were significantly reduced among patients with improved ΔeGFR. CONCLUSION Comprehensive multidisciplinary care of outpatients might help prevent worsening renal function among patients with CKD.
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