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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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Liu P, Quinn RR, Cortese G, Mahsin M, James MT, Ronksley PE, Quan H, Manns B, Hemmelgarn BR, Tonelli M, Ravani P. Nephrology consultation and kidney failure in people with stage 4 chronic kidney disease: a population-based cohort study. J Nephrol 2020; 34:1225-1234. [PMID: 33211302 DOI: 10.1007/s40620-020-00892-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/21/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Guidelines recommend referral for nephrology consultation for people with severe chronic kidney disease (CKD) to improve care and renal outcomes, yet the advocated benefits of nephrology referral on CKD progression in this patient population are unclear. METHODS We linked laboratory and administrative data in Alberta, Canada to identify adults with stage 4 CKD between 2002 and 2014 (follow-up end on March 31, 2017). We studied the association between time-varying receipt of outpatient nephrology consultation and kidney failure (the earlier of renal replacement initiation or eGFR < 10 mL/min/1.73 m2 for more than 3 months), accounting for the competing risk of death. RESULTS Of the 14,382 participants, 41% were ≥ 85 years old, 33% saw a nephrologist as an outpatient, 9% developed kidney failure, and 53% died over a median of 2.6 years. Compared with people who did not see a nephrologist before or at 7 months (median time to consultation), those who did were more likely to develop kidney failure [5-year risk (95% CI) 0.23 (0.21-0.24) vs 0.07 (0.065-0.075)]. With increasing age or higher eGFR, the 5-year risk of kidney failure became progressively smaller, from 0.24 (0.18-0.29) at age < 65 to 0.01 (0.006-0.015) at age ≥ 85 years and from 0.21 (0.18-0.23) at eGFR 15-19 to 0.066 (0.060-0.072) at eGFR 25-29 mL/min/1.73 m2; yet, the hazard ratio of kidney failure (1.6-4.3) increased following nephrology consultation in people who were older or had higher eGFR. CONCLUSIONS Adults with stage 4 CKD who see a nephrologist are more likely to develop kidney failure than those who don't, especially within lower absolute risk categories. Although selective referral may explain these findings, there is no evidence of an association between nephrology care and reduced risk of kidney failure in people with severe CKD. Studies are needed to assess the benefits of nephrology consultation in people with moderate CKD.
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Affiliation(s)
- Ping Liu
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, 3230 Hospital Drive N.W., Calgary, AB, T2N 4Z6, Canada
| | - Robert R Quinn
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, 3230 Hospital Drive N.W., Calgary, AB, T2N 4Z6, Canada
| | - Giuliana Cortese
- Department of Statistical Sciences, University of Padova, Padua, Italy
| | - Mohamed Mahsin
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, 3230 Hospital Drive N.W., Calgary, AB, T2N 4Z6, Canada
| | - Matthew T James
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, 3230 Hospital Drive N.W., Calgary, AB, T2N 4Z6, Canada
| | - Paul E Ronksley
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, 3230 Hospital Drive N.W., Calgary, AB, T2N 4Z6, Canada
| | - Hude Quan
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, 3230 Hospital Drive N.W., Calgary, AB, T2N 4Z6, Canada
| | - Braden Manns
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, 3230 Hospital Drive N.W., Calgary, AB, T2N 4Z6, Canada
| | - Brenda R Hemmelgarn
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, 3230 Hospital Drive N.W., Calgary, AB, T2N 4Z6, Canada
| | - Marcello Tonelli
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, 3230 Hospital Drive N.W., Calgary, AB, T2N 4Z6, Canada
| | - Pietro Ravani
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, 3230 Hospital Drive N.W., Calgary, AB, T2N 4Z6, Canada.
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3
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Liu P, Quinn RR, Karim ME, Bello A, Tam-Tham H, Weaver R, Ronksley PE, Quan H, Strippoli GFM, Manns B, Hemmelgarn BR, Tonelli M, Ravani P. Nephrology consultation and mortality in people with stage 4 chronic kidney disease: a population-based study. CMAJ 2019; 191:E274-E282. [PMID: 30858183 DOI: 10.1503/cmaj.181372] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Guidelines recommend nephrology referral for people with advanced non-dialysis-dependent chronic kidney disease, based mostly on survival benefits seen in retrospective studies of dialysis patients, which may not be generalizable to the broader population with chronic kidney disease. We aimed to examine the association between outpatient nephrology consultation and survival in adults with stage 4 chronic kidney disease. METHODS We linked population-based laboratory and administrative data from 2002 to 2014 in Alberta, Canada, on adults with stage 4 chronic kidney disease (sustained estimated glomerular filtration rate ≥ 15 to < 30 mL/min/1.73 m2 for > 90 d), who had never had kidney failure and had had no outpatient nephrology encounter in the 2 years preceding study entry. Participants who had never had an outpatient nephrology visit before renal replacement treatment were considered "unexposed." Participants who saw a nephrologist during follow-up were considered "unexposed" before the first outpatient nephrology visit and "exposed" thereafter. The primary outcome was all-cause mortality. RESULTS Of the 14 382 study participants (median follow-up 2.7 yr), 64% were aged ≥ 80 years, 35% saw a nephrologist and 66% died during follow-up. Nephrology consultation was associated with lower mortality (hazard ratio [HR] 0.88, 95% confidence interval [CI] 0.82-0.93). The association was strongest in people < 70 years (HR 0.78, 95% CI, 0.65-0.92), progressively weaker with increasing age, and absent in people ≥ 90 years (HR 1.05, 95% CI 0.88-1.25). INTERPRETATION The survival benefit of nephrology consultation in adults with stage 4 chronic kidney disease may be smaller than expected and appears to attenuate with increasing age. These findings should inform recommendations for nephrology referral considering the advanced age of the patient population meeting current referral criteria.
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Affiliation(s)
- Ping Liu
- Departments of Medicine and Community Health Sciences (Liu, Quinn, Tam-Tham, Weaver, Ronksley, Quan, Manns, Hemmelgarn, Tonelli, Ravani), University of Calgary, Calgary, Alta.; School of Population and Public Health (Karim), The University of British Columbia; Department of Medicine (Bello), University of Alberta, Edmonton, Alta.; Department of Emergency and Organ Transplantation (Strippoli), University of Bari, Bari, Italy
| | - Robert R Quinn
- Departments of Medicine and Community Health Sciences (Liu, Quinn, Tam-Tham, Weaver, Ronksley, Quan, Manns, Hemmelgarn, Tonelli, Ravani), University of Calgary, Calgary, Alta.; School of Population and Public Health (Karim), The University of British Columbia; Department of Medicine (Bello), University of Alberta, Edmonton, Alta.; Department of Emergency and Organ Transplantation (Strippoli), University of Bari, Bari, Italy
| | - Mohammad Ehsanul Karim
- Departments of Medicine and Community Health Sciences (Liu, Quinn, Tam-Tham, Weaver, Ronksley, Quan, Manns, Hemmelgarn, Tonelli, Ravani), University of Calgary, Calgary, Alta.; School of Population and Public Health (Karim), The University of British Columbia; Department of Medicine (Bello), University of Alberta, Edmonton, Alta.; Department of Emergency and Organ Transplantation (Strippoli), University of Bari, Bari, Italy
| | - Aminu Bello
- Departments of Medicine and Community Health Sciences (Liu, Quinn, Tam-Tham, Weaver, Ronksley, Quan, Manns, Hemmelgarn, Tonelli, Ravani), University of Calgary, Calgary, Alta.; School of Population and Public Health (Karim), The University of British Columbia; Department of Medicine (Bello), University of Alberta, Edmonton, Alta.; Department of Emergency and Organ Transplantation (Strippoli), University of Bari, Bari, Italy
| | - Helen Tam-Tham
- Departments of Medicine and Community Health Sciences (Liu, Quinn, Tam-Tham, Weaver, Ronksley, Quan, Manns, Hemmelgarn, Tonelli, Ravani), University of Calgary, Calgary, Alta.; School of Population and Public Health (Karim), The University of British Columbia; Department of Medicine (Bello), University of Alberta, Edmonton, Alta.; Department of Emergency and Organ Transplantation (Strippoli), University of Bari, Bari, Italy
| | - Robert Weaver
- Departments of Medicine and Community Health Sciences (Liu, Quinn, Tam-Tham, Weaver, Ronksley, Quan, Manns, Hemmelgarn, Tonelli, Ravani), University of Calgary, Calgary, Alta.; School of Population and Public Health (Karim), The University of British Columbia; Department of Medicine (Bello), University of Alberta, Edmonton, Alta.; Department of Emergency and Organ Transplantation (Strippoli), University of Bari, Bari, Italy
| | - Paul E Ronksley
- Departments of Medicine and Community Health Sciences (Liu, Quinn, Tam-Tham, Weaver, Ronksley, Quan, Manns, Hemmelgarn, Tonelli, Ravani), University of Calgary, Calgary, Alta.; School of Population and Public Health (Karim), The University of British Columbia; Department of Medicine (Bello), University of Alberta, Edmonton, Alta.; Department of Emergency and Organ Transplantation (Strippoli), University of Bari, Bari, Italy
| | - Hude Quan
- Departments of Medicine and Community Health Sciences (Liu, Quinn, Tam-Tham, Weaver, Ronksley, Quan, Manns, Hemmelgarn, Tonelli, Ravani), University of Calgary, Calgary, Alta.; School of Population and Public Health (Karim), The University of British Columbia; Department of Medicine (Bello), University of Alberta, Edmonton, Alta.; Department of Emergency and Organ Transplantation (Strippoli), University of Bari, Bari, Italy
| | - Giovanni F M Strippoli
- Departments of Medicine and Community Health Sciences (Liu, Quinn, Tam-Tham, Weaver, Ronksley, Quan, Manns, Hemmelgarn, Tonelli, Ravani), University of Calgary, Calgary, Alta.; School of Population and Public Health (Karim), The University of British Columbia; Department of Medicine (Bello), University of Alberta, Edmonton, Alta.; Department of Emergency and Organ Transplantation (Strippoli), University of Bari, Bari, Italy
| | - Braden Manns
- Departments of Medicine and Community Health Sciences (Liu, Quinn, Tam-Tham, Weaver, Ronksley, Quan, Manns, Hemmelgarn, Tonelli, Ravani), University of Calgary, Calgary, Alta.; School of Population and Public Health (Karim), The University of British Columbia; Department of Medicine (Bello), University of Alberta, Edmonton, Alta.; Department of Emergency and Organ Transplantation (Strippoli), University of Bari, Bari, Italy
| | - Brenda R Hemmelgarn
- Departments of Medicine and Community Health Sciences (Liu, Quinn, Tam-Tham, Weaver, Ronksley, Quan, Manns, Hemmelgarn, Tonelli, Ravani), University of Calgary, Calgary, Alta.; School of Population and Public Health (Karim), The University of British Columbia; Department of Medicine (Bello), University of Alberta, Edmonton, Alta.; Department of Emergency and Organ Transplantation (Strippoli), University of Bari, Bari, Italy
| | - Marcello Tonelli
- Departments of Medicine and Community Health Sciences (Liu, Quinn, Tam-Tham, Weaver, Ronksley, Quan, Manns, Hemmelgarn, Tonelli, Ravani), University of Calgary, Calgary, Alta.; School of Population and Public Health (Karim), The University of British Columbia; Department of Medicine (Bello), University of Alberta, Edmonton, Alta.; Department of Emergency and Organ Transplantation (Strippoli), University of Bari, Bari, Italy
| | - Pietro Ravani
- Departments of Medicine and Community Health Sciences (Liu, Quinn, Tam-Tham, Weaver, Ronksley, Quan, Manns, Hemmelgarn, Tonelli, Ravani), University of Calgary, Calgary, Alta.; School of Population and Public Health (Karim), The University of British Columbia; Department of Medicine (Bello), University of Alberta, Edmonton, Alta.; Department of Emergency and Organ Transplantation (Strippoli), University of Bari, Bari, Italy
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Kabinga SK, Ngigi JN, Kayima JK, McLigeyo SO. Predialysis Care Experience Among Patients With CKD at a Teaching Hospital in Kenya. Kidney Int Rep 2019; 4:1638-1641. [PMID: 31891006 PMCID: PMC6933452 DOI: 10.1016/j.ekir.2019.08.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 08/13/2019] [Accepted: 08/19/2019] [Indexed: 11/19/2022] Open
Affiliation(s)
- Samuel K. Kabinga
- East African Kidney Institute, University of Nairobi, Nairobi, Kenya
| | - John N. Ngigi
- Renal Department, Kenyatta National Hospital, Nairobi, Kenya
| | - Joshua K. Kayima
- East African Kidney Institute, University of Nairobi, Nairobi, Kenya
| | - Seth O. McLigeyo
- East African Kidney Institute, University of Nairobi, Nairobi, Kenya
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5
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Lu JL, Molnar MZ, Sumida K, Diskin CD, Streja E, Siddiqui OA, Kalantar-Zadeh K, Kovesdy CP. Association of the frequency of pre-end-stage renal disease medical care with post-end-stage renal disease mortality and hospitalization. Nephrol Dial Transplant 2019; 33:789-795. [PMID: 29106625 DOI: 10.1093/ndt/gfx192] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 04/23/2017] [Indexed: 11/12/2022] Open
Abstract
Background Previous studies have demonstrated that early pre-end-stage renal disease (ESRD) nephrology care could improve postdialysis prognosis. However, less is known about the specific types of interventions responsible for the improved outcomes. We hypothesized that more frequent predialysis laboratory testing is associated with better postdialysis outcomes in incident ESRD patients. Methods In all, 23 089 patients with available outpatient laboratory tests performed during the 2-year predialysis (i.e. prelude) period were identified from a total of 52 172 American veterans with chronic kidney disease (CKD) transitioning to dialysis between October 2007 and September 2011. The associations between the frequency of combined laboratory tests, including serum creatinine, serum potassium and hemoglobin (test trio), with postdialysis mortality and hospitalization were examined in multivariable adjusted Cox and logistic regression models. Results When entering the 2-year prelude period, the mean age (Standard Deviation) of the patients was 66.2 (SD 11.3) years and the mean estimated glomerular filtration rate was 46.8 (SD 23.9) mL/min/1.73 m2. In all, 14% of patients had the test trio performed less than twice in 24 months and 8.9% had the trio measured more often than every other month. Over a 2.5-year median postdialysis follow-up period, 15 303 (66.3%) patients died (mortality rate 260/1000 patient-years). The adjusted hazard ratio of all-cause mortality and adjusted odds ratio of the composite of hospitalization or death associated with lab testing done >12/24 months compared with 2-≤4/24 months were 0.68 [95% confidence interval (CI) 0.65-0.73] and 0.70 (95% CI 0.62-0.79), respectively. Conclusions More frequent laboratory testing in patients with advanced CKD is associated with better clinical outcomes after dialysis. Further examination in clinical trials is needed before the implementation of more frequent laboratory testing in clinical practice.
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Affiliation(s)
- Jun Ling Lu
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Miklos Z Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Keiichi Sumida
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.,Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan.,Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Charles D Diskin
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Omer A Siddiqui
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.,Nephrology Section, Memphis VA Medical Center, Memphis, TN, USA
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6
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Nicoll R, Robertson L, Gemmell E, Sharma P, Black C, Marks A. Models of care for chronic kidney disease: A systematic review. Nephrology (Carlton) 2018; 23:389-396. [PMID: 29160599 DOI: 10.1111/nep.13198] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2017] [Indexed: 11/24/2022]
Abstract
AIM Chronic kidney disease (CKD) is common and presents an increasing burden to patients and health services. However, the optimal model of care for patients with CKD is unclear. We systematically reviewed the clinical effectiveness of different models of care for the management of CKD. METHODS A comprehensive search of eight databases was undertaken for articles published from 1992 to 2016. We included randomized controlled trials that assessed any model of care in the management of adults with pre-dialysis CKD, reporting renal, cardiovascular, mortality and other outcomes. Data extraction and quality assessment was carried out independently by two authors. RESULTS Results were summarized narratively. Nine articles (seven studies) were included. Four models of care were identified: nurse-led, multidisciplinary specialist team, pharmacist-led and self-management. Nurse and pharmacist-led care reported improved rates of prescribing of drugs relevant to CKD. Heterogeneity was high between studies and all studies were at high risk of bias. Nurse-led care and multidisciplinary specialist care were associated with small improvements in blood pressure control. CONCLUSION Evidence of long term improvements in renal, cardiovascular or mortality endpoints was limited by short follow up. We found little published evidence about the effectiveness of different models of care to guide best practice for service design, although there was some evidence that models of care where health professionals deliver care according to a structured protocol or guideline may improve adherence to treatment targets.
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Affiliation(s)
- Ruairidh Nicoll
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Lynn Robertson
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Elliot Gemmell
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Pawana Sharma
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Corri Black
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK.,The Farr Institute of Health Informatics Research, Aberdeen, UK
| | - Angharad Marks
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
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7
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Low S, Lim SC, Wang J, Yeoh LY, Liu YL, Lim EK, Shao YL, Chui W, Fun S, Chua CL, Subramaniam T, Sum CF. Long-term outcomes of patients with type 2 diabetes attending a multidisciplinary diabetes kidney disease clinic. J Diabetes 2018; 10:572-580. [PMID: 29154443 DOI: 10.1111/1753-0407.12626] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 10/11/2017] [Accepted: 11/13/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The best model of care to retard diabetic kidney disease (DKD) in the clinic is underexplored. In this study we investigated the long-term renal outcomes of a joint endocrinologist-nephrologist clinic. METHODS The present study was a nested case-control study derived from a cohort of patients with type 2 diabetes mellitus (T2DM) seen prospectively at a secondary care diabetes center (DC). Cases ("DKD clinic group") were patients seen at the CKD clinic after being referred by physicians in DCs for management of DKD. Controls ("non-DKD clinic group") were patients from the same DC (i.e. same source population) with the same inclusion criteria of Stages 3-4 chronic kidney disease (CKD) at baseline but not seen at the DKD clinic. The outcome was Stage 5 CKD, defined as an estimated glomerular filtration rate <15 mL/min per 1.73 m2 . RESULTS During the median follow-up period of 3.0 years (interquartile range 1.2-5.1 years), 240 patients (28.7%) reached Stage 5 CKD, with 45.8% and 54.2% of those reaching Stage 5 CKD in the DKD and non-DKD clinic groups, respectively. Multivariable Cox regression revealed that the DKD clinic group had a lower risk of progressing to Stage 5 CKD (hazard ratio 0.55; 95% confidence interval 0.36-0.83; P = 0.004) compared with the non-DKD clinic group. CONCLUSIONS Multidisciplinary endocrinology and nephrology care in the DKD clinic is associated with a lower risk of end-stage renal disease. These findings may inform future management strategies targeted at patients with T2DM and CKD, especially with regard to joint specialist management involving endocrinologists and nephrologists.
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Affiliation(s)
- Serena Low
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore
| | - Su Chi Lim
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore
- Diabetes Centre, Khoo Teck Puat Hospital, Singapore
| | - Jiexun Wang
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore
| | - Lee Ying Yeoh
- Department of Medicine, Khoo Teck Puat Hospital, Singapore
| | - Yan Lun Liu
- Department of Medicine, Khoo Teck Puat Hospital, Singapore
| | - Eng Kuang Lim
- Department of Medicine, Khoo Teck Puat Hospital, Singapore
| | - Yan Li Shao
- Diabetes Centre, Khoo Teck Puat Hospital, Singapore
| | - Winnie Chui
- Diabetes Centre, Khoo Teck Puat Hospital, Singapore
| | - Sharon Fun
- Diabetes Centre, Khoo Teck Puat Hospital, Singapore
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8
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Valentijn PP, Pereira FA, Ruospo M, Palmer SC, Hegbrant J, Sterner CW, Vrijhoef HJM, Ruwaard D, Strippoli GFM. Person-Centered Integrated Care for Chronic Kidney Disease: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Clin J Am Soc Nephrol 2018; 13:375-386. [PMID: 29438975 PMCID: PMC5967678 DOI: 10.2215/cjn.09960917] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 12/15/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND OBJECTIVES The effectiveness of person-centered integrated care strategies for CKD is uncertain. We conducted a systematic review and meta-analysis of randomized, controlled trials to assess the effect of person-centered integrated care for CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We searched MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (from inception to April of 2016), and selected randomized, controlled trials of person-centered integrated care interventions with a minimum follow-up of 3 months. Random-effects meta-analysis was used to assess the effect of person-centered integrated care. RESULTS We included 14 eligible studies covering 4693 participants with a mean follow-up of 12 months. In moderate quality evidence, person-centered integrated care probably had no effect on all-cause mortality (relative risk [RR], 0.86; 95% confidence interval [95% CI], 0.68 to 1.08) or health-related quality of life (standardized mean difference, 0.02; 95% CI, -0.05 to 0.10). The effects on renal replacement therapy (RRT) (RR, 1.00; 95% CI, 0.65 to 1.55), serum creatinine levels (mean difference, 0.59 mg/dl; 95% CI, -0.38 to 0.36), and eGFR (mean difference, 1.51 ml/min per 1.73 m2; 95% CI, -3.25 to 6.27) were very uncertain. Quantitative analysis suggested that person-centered integrated care interventions may reduce all-cause hospitalization (RR, 0.38; 95% CI, 0.15 to 0.95) and improve BP control (RR, 1.20; 95% CI, 1.00 to 1.44), although the certainty of the evidence was very low. CONCLUSIONS Person-centered integrated care may have little effect on mortality or quality of life. The effects on serum creatinine, eGFR, and RRT are uncertain, although person-centered integrated care may lead to fewer hospitalizations and improved BP control.
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Affiliation(s)
- Pim P Valentijn
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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9
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Lin E, Chertow GM, Yan B, Malcolm E, Goldhaber-Fiebert JD. Cost-effectiveness of multidisciplinary care in mild to moderate chronic kidney disease in the United States: A modeling study. PLoS Med 2018; 15:e1002532. [PMID: 29584720 PMCID: PMC5870947 DOI: 10.1371/journal.pmed.1002532] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 02/14/2018] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Multidisciplinary care (MDC) programs have been proposed as a way to alleviate the cost and morbidity associated with chronic kidney disease (CKD) in the US. METHODS AND FINDINGS We assessed the cost-effectiveness of a theoretical Medicare-based MDC program for CKD compared to usual CKD care in Medicare beneficiaries with stage 3 and 4 CKD between 45 and 84 years old in the US. The program used nephrologists, advanced practitioners, educators, dieticians, and social workers. From Medicare claims and published literature, we developed a novel deterministic Markov model for CKD progression and calibrated it to long-term risks of mortality and progression to end-stage renal disease. We then used the model to project accrued discounted costs and quality-adjusted life years (QALYs) over patients' remaining lifetime. We estimated the incremental cost-effectiveness ratio (ICER) of MDC, or the cost of the intervention per QALY gained. MDC added 0.23 (95% CI: 0.08, 0.42) QALYs over usual care, costing $51,285 per QALY gained (net monetary benefit of $23,100 at a threshold of $150,000 per QALY gained; 95% CI: $6,252, $44,323). In all subpopulations analyzed, ICERs ranged from $42,663 to $72,432 per QALY gained. MDC was generally more cost-effective in patients with higher urine albumin excretion. Although ICERs were higher in younger patients, MDC could yield greater improvements in health in younger than older patients. MDC remained cost-effective when we decreased its effectiveness to 25% of the base case or increased the cost 5-fold. The program costed less than $70,000 per QALY in 95% of probabilistic sensitivity analyses and less than $87,500 per QALY in 99% of analyses. Limitations of our study include its theoretical nature and being less generalizable to populations at low risk for progression to ESRD. We did not study the potential impact of MDC on hospitalization (cardiovascular or other). CONCLUSIONS Our model estimates that a Medicare-funded MDC program could reduce the need for dialysis, prolong life expectancy, and meet conventional cost-effectiveness thresholds in middle-aged to elderly patients with mild to moderate CKD.
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Affiliation(s)
- Eugene Lin
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, United States of America.,Center for Health Policy/Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Palo Alto, California, United States of America
| | - Glenn M Chertow
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, United States of America
| | - Brandon Yan
- Duke University, Durham, North Carolina, United States of America
| | - Elizabeth Malcolm
- Division of General Medical Disciplines, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, United States of America
| | - Jeremy D Goldhaber-Fiebert
- Center for Health Policy/Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Palo Alto, California, United States of America
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Shi Y, Xiong J, Chen Y, Deng J, Peng H, Zhao J, He J. The effectiveness of multidisciplinary care models for patients with chronic kidney disease: a systematic review and meta-analysis. Int Urol Nephrol 2017; 50:301-312. [PMID: 28856498 PMCID: PMC5811573 DOI: 10.1007/s11255-017-1679-7] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 08/14/2017] [Indexed: 01/12/2023]
Abstract
Aim To assess the efficacy of the multidisciplinary care (MDC) model for patients with chronic kidney disease (CKD). Background The MDC model has been used in clinical practice for years, but the effectiveness of the MDC model for patients with CKD remains controversial. Methods Embase, PubMed, Medline, the Cochrane Library, and China National Knowledge Infrastructure databases were used to search for relevant articles. Only randomized controlled trials and cohort studies were pooled. Two independent authors assessed all articles and extracted the data. The efficacy was estimated from the odds ratios and corresponding 95% confidence intervals. A random effects model was used according to the heterogeneity. Results Twenty-one studies including 10,284 participants were analyzed. Compared with the non-MDC group, MDC was associated with a lower risk of all-cause mortality and lower hospitalization rates for patients with CKD. In addition, MDC also resulted in a slower eGFR decline and reduced temporary catheterization for patients receiving dialysis. However, according to the subgroup analysis, the lower rates of all-cause mortality in the MDC group were observed only in patients in stage 4–5 and when the staff of the MDC consisted of nephrologists, nurse specialists and professionals from other fields. The most prominent effect of reducing the hospitalization rates was also observed in patients with stage 4–5 but not in patients with stage 4–5 CKD. Conclusions MDC can lower the all-cause mortality of patients with CKD, reduce temporary catheterization for patients receiving dialysis, decrease the hospitalization rate, and slow the eGFR decline. Moreover, the reduction in all-cause mortality crucially depends on the professionals comprising the MDC staff and the stage of CKD in patients. In addition, the CKD stage influences the hospitalization rates.
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Affiliation(s)
- Yu Shi
- Institute of Nephrology of Chongqing and Kidney Center of PLA, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Jiachuan Xiong
- Institute of Nephrology of Chongqing and Kidney Center of PLA, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Yan Chen
- Institute of Nephrology of Chongqing and Kidney Center of PLA, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Junna Deng
- Institute of Nephrology of Chongqing and Kidney Center of PLA, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Hongmei Peng
- Institute of Nephrology of Chongqing and Kidney Center of PLA, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Jinghong Zhao
- Institute of Nephrology of Chongqing and Kidney Center of PLA, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Jing He
- Institute of Nephrology of Chongqing and Kidney Center of PLA, Xinqiao Hospital, Third Military Medical University, Chongqing, China.
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11
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Johnson DS, Kapoian T, Taylor R, Meyer KB. Going Upstream: Coordination to Improve CKD Care. Semin Dial 2016; 29:125-34. [PMID: 26765792 DOI: 10.1111/sdi.12461] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Care coordination for patients with chronic kidney disease has been shown to be effective in improving outcomes and reducing costs. However, few patients with CKD benefit from this systematic management of their kidney disease and other medical conditions. As a result, outcomes for patients with kidney disease are not optimal, and their cost of care is increased. For those patients who transition to kidney failure treatment in the United States, the transition does not go as well as it could. The effectiveness of treatments to delay progression of kidney disease in contemporary clinical practice does not match the efficacy of these treatments in clinical trials. Conservative care for kidney disease, which should be an option for patients who are very old and very sick, is not considered often enough or seriously enough. Opportunities for early and even pre-emptive transplantation are missed, as are opportunities for home dialysis. The process of dialysis access creation is rarely optimal. The consequence is care which is not as good as it could be, and much more expensive than it should be. We describe our initial efforts to implement care coordination for chronic kidney disease in routine clinical care and attempt to project some of the benefits to patients and the cost savings.
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Affiliation(s)
| | - Toros Kapoian
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey.,Dialysis Clinic, Inc., North Brunswick, New Jersey
| | - Robert Taylor
- Dialysis Clinic, Inc., Nashville, Tennessee.,Nephrology Associates, Nashville, Tennessee
| | - Klemens B Meyer
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
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12
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Dixon BE, Whipple EC, Lajiness JM, Murray MD. Utilizing an integrated infrastructure for outcomes research: a systematic review. Health Info Libr J 2015; 33:7-32. [PMID: 26639793 DOI: 10.1111/hir.12127] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 10/16/2015] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To explore the ability of an integrated health information infrastructure to support outcomes research. METHODS A systematic review of articles published from 1983 to 2012 by Regenstrief Institute investigators using data from an integrated electronic health record infrastructure involving multiple provider organisations was performed. Articles were independently assessed and classified by study design, disease and other metadata including bibliometrics. RESULTS A total of 190 articles were identified. Diseases included cognitive, (16) cardiovascular, (16) infectious, (15) chronic illness (14) and cancer (12). Publications grew steadily (26 in the first decade vs. 100 in the last) as did the number of investigators (from 15 in 1983 to 62 in 2012). The proportion of articles involving non-Regenstrief authors also expanded from 54% in the first decade to 72% in the last decade. During this period, the infrastructure grew from a single health system into a health information exchange network covering more than 6 million patients. Analysis of journal and article metrics reveals high impact for clinical trials and comparative effectiveness research studies that utilised data available in the integrated infrastructure. DISCUSSION Integrated information infrastructures support growth in high quality observational studies and diverse collaboration consistent with the goals for the learning health system. More recent publications demonstrate growing external collaborations facilitated by greater access to the infrastructure and improved opportunities to study broader disease and health outcomes. CONCLUSIONS Integrated information infrastructures can stimulate learning from electronic data captured during routine clinical care but require time and collaboration to reach full potential.
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Affiliation(s)
- Brian E Dixon
- Richard M. Fairbanks School of Public Health at IUPUI, Indianapolis, IN, USA.,Regenstrief Institute, Inc., Indianapolis, IN, USA.,Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13-416, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Elizabeth C Whipple
- Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Michael D Murray
- Regenstrief Institute and Purdue University, Indianapolis, IN, USA
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13
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Wang SM, Hsiao LC, Ting IW, Yu TM, Liang CC, Kuo HL, Chang CT, Liu JH, Chou CY, Huang CC. Multidisciplinary care in patients with chronic kidney disease: A systematic review and meta-analysis. Eur J Intern Med 2015; 26:640-5. [PMID: 26186813 DOI: 10.1016/j.ejim.2015.07.002] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 07/01/2015] [Accepted: 07/02/2015] [Indexed: 01/10/2023]
Abstract
BACKGROUND Multidisciplinary care (MDC) was widely used in multiple chronic illnesses but the effectiveness of MDC in patients with chronic kidney disease (CKD) was inconclusive. The aim of this meta-analysis is to estimate the effectiveness of MDC for CKD. METHODS We searched PubMed, Web of Science, Google Scholar, Cochrane Library, and China Journal Full-text Database for relevant articles published in English or Chinese. Studies investigating MDC and non-MDC in patients with CKD were included. Random effect model was used to compare all-cause mortality, dialysis, risk of temporal catheterization, and hospitalization in the two treatment entities. RESULTS We analyzed 8853 patients of 18 studies in patients with CKD stages 3-5, aged 63±12 years. MDC was associated with lower risk of all-cause mortality with an odds ratio (OR) of 0.52 [95% confidence interval (CI): 0.44-0.88, p=0.01], mainly in cohort studies. MDC was associated with a lower risk of starting dialysis (p=0.02) and lower risk of temporal catheterization for dialysis (p<0.01). MDC was not associated with a higher chance of choosing peritoneal dialysis (p=0.18) or a lower chance of hospitalization for dialysis (p=0.13). CONCLUSIONS Limited evidence from randomized controlled trials is currently available to support the benefit of MDC in patients with CKD. MDC is associated with lower all-cause mortality, lower risk of starting dialysis, and lower risk of temporal catheterization for dialysis in cohort studies. MDC is not associated with a higher chance of choosing peritoneal dialysis or a lower chance of hospitalization for dialysis. More studies are needed to determine the optimal professional that should be included in MDC.
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Affiliation(s)
- Su-Ming Wang
- Kidney Institute and Division of Nephrology, China Medical University Hospital, Taichung, Taiwan; College of Medicine, China Medical University, Taichung, Taiwan
| | - Lien-Cheng Hsiao
- College of Medicine, China Medical University, Taichung, Taiwan; Division of Cardiology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - I-Wen Ting
- Kidney Institute and Division of Nephrology, China Medical University Hospital, Taichung, Taiwan; College of Medicine, China Medical University, Taichung, Taiwan
| | - Tung-Min Yu
- College of Medicine, China Medical University, Taichung, Taiwan; Division of Nephrology, Department of Medicine, Taichung Veterans General Hospital, Taiwan
| | - Chih-Chia Liang
- Kidney Institute and Division of Nephrology, China Medical University Hospital, Taichung, Taiwan; College of Medicine, China Medical University, Taichung, Taiwan
| | - Huey-Liang Kuo
- Kidney Institute and Division of Nephrology, China Medical University Hospital, Taichung, Taiwan; College of Medicine, China Medical University, Taichung, Taiwan
| | - Chiz-Tzung Chang
- Kidney Institute and Division of Nephrology, China Medical University Hospital, Taichung, Taiwan; College of Medicine, China Medical University, Taichung, Taiwan
| | - Jiung-Hsiun Liu
- Kidney Institute and Division of Nephrology, China Medical University Hospital, Taichung, Taiwan; College of Medicine, China Medical University, Taichung, Taiwan
| | - Che-Yi Chou
- Kidney Institute and Division of Nephrology, China Medical University Hospital, Taichung, Taiwan; College of Medicine, China Medical University, Taichung, Taiwan.
| | - Chiu-Ching Huang
- Kidney Institute and Division of Nephrology, China Medical University Hospital, Taichung, Taiwan; College of Medicine, China Medical University, Taichung, Taiwan
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14
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Espahbodi F, Hosseini H, Mirzade MM, Shafaat AB. Effect of Psycho Education on Depression and Anxiety Symptoms in Patients on Hemodialysis. IRANIAN JOURNAL OF PSYCHIATRY AND BEHAVIORAL SCIENCES 2015; 9:e227. [PMID: 26251661 PMCID: PMC4525450 DOI: 10.17795/ijpbs227] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 10/28/2014] [Accepted: 12/29/2014] [Indexed: 11/28/2022]
Abstract
Background: Hemodialysis as a solution for patients with chronic renal failure is a stressful process. Anxiety and depression after hemodialysis could have negative impacts on quality of life, treatment and prognosis of the disease. Some studies indicated that educating patients prior to hemodialysis could enhance patients’ quality of life and increase the likelihood of their survival. Objectives: This study investigated psychological impacts of psycho education on anxiety and depression symptoms in patients under dialysis. Patients and Methods: This was a prospective, experimental intervention study with pretest and post-test. Eligible patients (n = 60) were selected randomly from dialysis center of Imam Khomeini Hospital in Sari in 2009. Hospital Anxiety Depression Scale (HADS) score of patients were eight or greater. They were divided into two matched groups. In one group, patients were given psycho education during three sessions of one-hour, while patients in the control group did not receive any education. HADS was completed for both groups before dialysis and one month after the end of educational sessions. The data were compared and analyzed using paired t-test and Chi-square test. Results: Psycho education decreased depression score (P < 0.001) and the HADS (P = 0.008) significantly. These decreases were not significant for anxiety scores of patients (P = 0.185). Conclusion: This research indicated that psycho education based on the designed protocol decreased the scores of depression and total scores of HADS.
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Affiliation(s)
- Fatemeh Espahbodi
- Department of Nephrology, School of Medicine, Mazandaran University of Medical Sciences, Sari, IR Iran
| | - Hamzeh Hosseini
- Department of Nephrology, School of Medicine, Mazandaran University of Medical Sciences, Sari, IR Iran ; Psychiatry and Behavioral Sciences Research Center, Addiction Institute and Department of Psychiatry, School of Medicine, Mazandaran University of Medical Sciences, Sari, IR Iran
| | | | - Arefeh Beygom Shafaat
- Department of Nephrology, School of Medicine, Mazandaran University of Medical Sciences, Sari, IR Iran
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15
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Saxena N, Rizk DV. The interdisciplinary team: the whole is larger than the parts. Adv Chronic Kidney Dis 2014; 21:333-7. [PMID: 24969383 DOI: 10.1053/j.ackd.2014.02.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 01/30/2014] [Accepted: 02/19/2014] [Indexed: 01/12/2023]
Abstract
Chronic kidney disease (CKD) is an emerging global health problem. Caring for CKD patients is a medical and financial challenge currently placing a significant burden on our health-care system. This creates an impetus to explore nontraditional models of care. In this article, we explore the role of interdisciplinary care clinics in managing the complex and multifaceted aspects of CKD. By having different providers work seamlessly in a synergistic and collaborative environment, there is less risk of fragmentation of care. In this patient-centered model of care, patients are empowered and engaged to achieve therapeutic targets, make lifestyle changes, and participate in decision-making. Timely referral and education delivered by advanced practitioners are 2 of the crucial elements central to the success of the interdisciplinary model. Further studies are needed to identify other key elements that would enhance the interdisciplinary approach to ensure that guideline-based therapeutic targets are reached and to define the subset of patients that would benefit the most. Innovative information technology solutions that could enhance the implementation of interdisciplinary clinics and expand their reach should be exploited. Lastly, for the paradigm shift to occur, the integrative approach should prove to be cost-effective.
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16
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Davis JS, Zuber K. The nephrology interdisciplinary team: an education synergism. Adv Chronic Kidney Dis 2014; 21:338-43. [PMID: 24969384 DOI: 10.1053/j.ackd.2014.03.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 03/01/2014] [Accepted: 03/17/2014] [Indexed: 11/11/2022]
Abstract
Patients with kidney disease often have a poor understanding of their condition. The interdisciplinary team can effectively educate these patients to slow disease progression and enhance self-management. The kidney community needs large, well-designed studies to determine the best way to educate patients and hopefully stem the tide of a rapidly increasing population of kidney patients. Congress authorized payment to eligible providers for kidney disease education for Medicare beneficiaries. However, this benefit is not being optimally used. In addition, reimbursement denials were 14-17% in 2011 and 20-23% in 2012. This is more than 4 times the usual Medicare denial rate for current procedural terminology (CPT) codes.
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17
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Smart NA, Dieberg G, Ladhani M, Titus T. Early referral to specialist nephrology services for preventing the progression to end-stage kidney disease. Cochrane Database Syst Rev 2014:CD007333. [PMID: 24938824 DOI: 10.1002/14651858.cd007333.pub2] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Early referral of patients with chronic kidney disease (CKD) is believed to help with interventions to address risk factors to slow down the rate of progression of kidney failure to end-stage kidney disease (ESKD) and the need for dialysis, hospitalisation and mortality. OBJECTIVES We sought to evaluate the benefits (reduced hospitalisation and mortality; increased quality of life) and harms (increased hospitalisations and mortality, decreased quality of life) of early versus late referral to specialist nephrology services in CKD patients who are progressing to ESKD and RRT. In this review, referral is defined as the time period between first nephrology evaluation and initiation of dialysis; early referral is more than one to six months, whereas late referral is less than one to six months prior to starting dialysis. All-cause mortality and hospitalisation and quality of life were measured by the visual analogue scale and SF-36. SF-36 and KDQoL are validated measurement instruments for kidney diseases. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2012; Issue 1) which contains the Cochrane Renal Group's Specialised Register; MEDLINE (1966 to February 2012), EMBASE (1980 to February 2012). Search terms were approved by the Trial Search Co-ordinator. SELECTION CRITERIA Randomised controlled trials (RCTs), quasi-RCTs, prospective and retrospective longitudinal cohort studies were eligible for inclusion. DATA COLLECTION AND ANALYSIS Two authors independently assessed study quality and extracted data. Events relating to adverse effects were collected from the studies. MAIN RESULTS No RCTs or quasi-RCTs were identified. There were 40 longitudinal cohort studies providing data on 63,887 participants; 43,209 (68%) who were referred early and 20,678 (32%) referred late.Comparative mortality was higher in patients referred to specialist services late versus those referred early. Risk ratios (RR) for mortality reductions in patients referred early were evident at three months (RR 0.61, 95% CI 0.55 to 0.67; I² = 84%) and remained at five years (RR 0.66, 95% CI 0.60 to 0.71; I² = 87%). Initial hospitalisation was 9.12 days shorter with early referral (95% CI -10.92 to -7.32 days; I² = 82%) compared to late referral. Pooled analysis showed patients referred early were more likely than late referrals to initiate RRT with peritoneal dialysis (RR 1.74, 95% CI 1.64 to 1.84; I² = 92%).Patients referred early were less likely to receive temporary vascular access (RR 0.47, 95% CL 0.45 to 0.50; I² = 97%) than those referred late. Patients referred early were more likely to receive permanent vascular access (RR 3.22, 95% CI 2.92 to 3.55; I² = 97%). Systolic blood pressure (BP) was significantly lower in early versus late referrals (MD -3.09 mm Hg, 95% CI -5.23 to -0.95; I² = 85%); diastolic BP was significantly lower in early versus late referrals (MD -1.64 mm Hg, 95% CI -2.77 to -0.51; I² = 82%). EPO use was significantly higher in those referred early (RR 2.92, 95% CI 2.42 to 3.52; I² = 0%). eGFR was higher in early referrals (MD 0.42 mL/min/1.73 m², 95% CI 0.28 to 0.56; I² = 95%). Diabetes prevalence was similar in patients referred early and late (RR 1.05, 95% CI 0.96 to 1.15; I² = 87%) as was ischaemic heart disease (RR 1.05, 95% CI 0.97 to 1.13; I² = 74%), peripheral vascular disease (RR 0.99, 95% CI 0.84 to 1.17; I² = 90%), and congestive heart failure (RR 1.00, 95% CI 0.86 to 1.15; I² = 92%). Inability to walk was less prevalent in early referrals (RR 0.66, 95% CI 0.51 to 0.86). Prevalence of chronic obstructive pulmonary disease was similar in those referred early and late (RR 0.89, 95% CI 0.70 to 1.14; I² = 94%) as was cerebrovascular disease (RR 0.90, 95% CI 0.74 to 1.11; I² = 83%).The quality of the included studies was assessed as being low to moderate based on the Newcastle-Ottawa Scale. Slight differences in the definition of early versus late referral infer some risk of bias. Generally, heterogeneity in most of the analyses was high. AUTHORS' CONCLUSIONS Our analysis showed reduced mortality and mortality and hospitalisation, better uptake of peritoneal dialysis and earlier placement of arteriovenous fistulae for patients with chronic kidney disease who were referred early to a nephrologist. Differences in mortality and hospitalisation data between the two groups were not explained by differences in prevalence of comorbid disease or serum phosphate. However, early referral was associated with better preparation and placement of dialysis access.
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Affiliation(s)
- Neil A Smart
- Exercise Physiology Convenor, University of New England, University Drive, Armidale, Australia, NSW 2351
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18
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Martínez-Ramírez HR, Cortés-Sanabria L, Rojas-Campos E, Hernández-Herrera A, Cueto-Manzano AM. Multidisciplinary Strategies in the Management of Early Chronic Kidney Disease. Arch Med Res 2013; 44:611-5. [DOI: 10.1016/j.arcmed.2013.10.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Accepted: 10/22/2013] [Indexed: 11/30/2022]
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Cueto-Manzano AM, Martínez-Ramírez HR, Cortés-Sanabria L. Comparison of primary health-care models in the management of chronic kidney disease. Kidney Int Suppl (2011) 2013; 3:210-214. [PMID: 25018986 PMCID: PMC4089658 DOI: 10.1038/kisup.2013.16] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Negative lifestyle habits (potential risks for chronic kidney disease, CKD) are rarely modified by physicians in a conventional health-care model (CHCM). Multidisciplinary strategies may have better results; however, there is no information on their application in the early stages of CKD. Thus, the aim of this study was to compare a multiple intervention model versus CHCM on lifestyle and renal function in patients with type 2 diabetes mellitus and CKD stage 1-2. In a prospective cohort study, a family medicine unit (FMU) was assigned a multiple intervention model (MIM) and another continued with conventional health-care model (CHCM). MIM patients received an educational intervention guided by a multidisciplinary team (family physician (FP), social worker, dietitian, physical trainer); self-help groups functioned with free activities throughout the study. CHCM patients were managed only by the FP, who decided if patients needed referral to other professionals. Thirty-nine patients were studied in each cohort. According to a lifestyle questionnaire, no baseline differences were found between cohorts, but results reflected an unhealthy lifestyle. After 6 months of follow-up, both cohorts showed significant improvement in their dietary habits. Compared to CHCM diet, exercise, emotional management, knowledge of disease, and adherence to treatment showed greater improvement in the MIM. Blood pressure decreased in both cohorts, but body mass index, waist circumference, and HbA1C significantly decreased only in MIM. Glomerular filtration rate (GFR) was maintained equally in both cohorts, but albuminuria significantly decreased only in MIM. In conclusion, MIM achieves better control of lifestyle-related variables and CKD risk factors in type 2 diabetes mellitus (DM2) patients with CKD stage 1-2. Broadly, implementation of a MIM in primary health care may produce superior results that might assist in preventing the progression of CKD.
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Affiliation(s)
- Alfonso M Cueto-Manzano
- Unidad de Investigación Médica en Enfermedades Renales, Hospital de Especialidades, Jalisco, Mexico
| | | | - Laura Cortés-Sanabria
- Unidad de Investigación Médica en Enfermedades Renales, Hospital de Especialidades, Jalisco, Mexico
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Teng HL, Yen M, Fetzer S, Sung JM, Hung SY. Effects of targeted interventions on lifestyle modifications of chronic kidney disease patients: randomized controlled trial. West J Nurs Res 2013; 35:1107-27. [PMID: 23618821 DOI: 10.1177/0193945913486202] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Targeting interventions to an individual's readiness to modify lifestyle factors, specifically diet and exercise behaviors, may delay chronic kidney disease (CKD) progression. This study examined the effects of a targeted Lifestyle Modification Program based on the readiness to change health-promotion lifestyle behaviors, renal protection knowledge, and physical indicators of patients with early CKD. A repeated-measures design randomized 160 CKD patients from four southern Taiwan outpatient nephrology clinics into control and intervention groups. Data were collected five times over a year with a participant retention rate of 64.4%. The intervention group demonstrated significant improvement with regard to diet behavior modifications. Compared with the control group, the intervention group showed a significant improving trend of renal function protection knowledge, stress management, and interpersonal relations. Targeted interventions for patients in the early phases of CKD promotes adherence to proper diet, exercise behavior, and positive lifestyle modifications.
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21
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Boudville N, Kemp A, Moody H, Fassett RG, Pedagogos E, Nelson C, Healy H, Mangos G, Kirkland G, Kay T, Champion de Crespigny P, Hoffman D, Waugh D. Factors associated with chronic kidney disease progression in Australian nephrology practices. Nephron Clin Pract 2012; 121:c36-41. [PMID: 23095346 DOI: 10.1159/000342375] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Accepted: 07/24/2012] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND/AIMS Chronic kidney disease (CKD) is a major health issue worldwide. The aim of this study was to explore factors associated with CKD progression in Australian nephrology practices. METHODS This was a retrospective study utilising an electronic medical record (EMR), Audit4 (Software for Specialists, Australia). The baseline visit was defined as the first entry into the EMR. The primary outcome was the rate of change in estimated glomerular filtration rate (eGFR). RESULTS 1,328 patients were included with a mean eGFR at baseline of 37.4 ± 0.7 ml/min/1.73 m(2), a mean follow-up of 17.7 months and a mean annual rate of change in eGFR of -0.84 ± 0.26 ml/min/1.73 m(2). Univariate analysis demonstrated that women, smokers, and patients prescribed erythropoiesis-stimulating agents (ESA) had a significantly more rapid decline in eGFR (p = 0.007, 0.033, and 0.003, respectively). On multivariate analysis: gender, age, prescription of ESA and phosphate binders, and baseline eGFR were significantly associated with CKD progression (p = 0.003, 0.004, <0.001, 0.029, and <0.001, respectively). CONCLUSIONS This study identifies potential factors associated with CKD progression in a population referred to nephrologists, but current data quality may result in bias. Implementation of changes in the format of data collection is required so that busy clinicians record essential information to enable this to become a more accurate and reliable research tool.
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Hayes SL, Mann MK, Morgan FM, Kelly MJ, Weightman AL. Collaboration between local health and local government agencies for health improvement. Cochrane Database Syst Rev 2012; 10:CD007825. [PMID: 23076937 PMCID: PMC9936257 DOI: 10.1002/14651858.cd007825.pub6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND In many countries, national, regional and local inter- and intra-agency collaborations have been introduced to improve health outcomes. Evidence is needed on the effectiveness of locally developed partnerships which target changes in health outcomes and behaviours. OBJECTIVES To evaluate the effects of interagency collaboration between local health and local government agencies on health outcomes in any population or age group. SEARCH METHODS We searched the Cochrane Public Health Group Specialised Register, AMED, ASSIA, CENTRAL, CINAHL, DoPHER, EMBASE, ERIC, HMIC, IBSS, MEDLINE, MEDLINE In-Process, OpenGrey, PsycINFO, Rehabdata, Social Care Online, Social Services Abstracts, Sociological Abstracts, TRoPHI and Web of Science from 1966 through to January 2012. 'Snowballing' methods were used, including expert contact, citation tracking, website searching and reference list follow-up. SELECTION CRITERIA Randomized controlled trials (RCTs), controlled clinical trials (CCTs), controlled before-and-after studies (CBAs) and interrupted time series (ITS) where the study reported individual health outcomes arising from interagency collaboration between health and local government agencies compared to standard care. Studies were selected independently in duplicate, with no restriction on population subgroup or disease. DATA COLLECTION AND ANALYSIS Two authors independently conducted data extraction and assessed risk of bias for each study. MAIN RESULTS Sixteen studies were identified (28,212 participants). Only two were considered to be at low risk of bias. Eleven studies contributed data to the meta-analyses but a narrative synthesis was undertaken for all 16 studies. Six studies examined mental health initiatives, of which one showed health benefit, four showed modest improvement in one or more of the outcomes measured but no clear overall health gain, and one showed no evidence of health gain. Four studies considered lifestyle improvements, of which one showed some limited short-term improvements, two failed to show health gains for the intervention population, and one showed more unhealthy lifestyle behaviours persisting in the intervention population. Three studies considered chronic disease management and all failed to demonstrate health gains. Three studies considered environmental improvements and adjustments, of which two showed some health improvements and one did not.Meta-analysis of three studies exploring the effect of collaboration on mortality showed no effect (pooled relative risk of 1.04 in favour of control, 95% CI 0.92 to 1.17). Analysis of five studies (with high heterogeneity) looking at the effect of collaboration on mental health resulted in a standardised mean difference of -0.28, a small effect favouring the intervention (95% CI -0.51 to -0.06). From two studies, there was a statistically significant but clinically modest improvement in the global assessment of function symptoms score scale, with a pooled mean difference (on a scale of 1 to 100) of -2.63 favouring the intervention (95% CI -5.16 to -0.10).For physical health (6 studies) and quality of life (4 studies) the results were not statistically significant, the standardised mean differences were -0.01 (95% CI -0.10 to 0.07) and -0.08 (95% CI -0.44 to 0.27), respectively. AUTHORS' CONCLUSIONS Collaboration between local health and local government is commonly considered best practice. However, the review did not identify any reliable evidence that interagency collaboration, compared to standard services, necessarily leads to health improvement. A few studies identified component benefits but these were not reflected in overall outcome scores and could have resulted from the use of significant additional resources. Although agencies appear enthusiastic about collaboration, difficulties in the primary studies and incomplete implementation of initiatives have prevented the development of a strong evidence base. If these weaknesses are addressed in future studies (for example by providing greater detail on the implementation of programmes; using more robust designs, integrated process evaluations to show how well the partners of the collaboration worked together, and measurement of health outcomes) it could provide a better understanding of what might work and why. It is possible that local collaborative partnerships delivering environmental Interventions may result in health gain but the evidence base for this is very limited.Evaluations of interagency collaborative arrangements face many challenges. The results demonstrate that collaborative community partnerships can be established to deliver interventions but it is important to agree goals, methods of working, monitoring and evaluation before implementation to protect programme fidelity and increase the potential for effectiveness.
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Affiliation(s)
- Sara L Hayes
- Abertawe Bro Morgannwg University Health BoardABM Headquarters1 Talbot GatewayPort TalbotUKSA12 7BR
| | - Mala K Mann
- Information Services, Cardiff UniversitySupport Unit for Research Evidence (SURE)1st Floor, Neuadd MeirionnyddHeath ParkCardiffWalesUKCF14 4YS
| | - Fiona M Morgan
- Information Services, Cardiff UniversitySupport Unit for Research Evidence (SURE)1st Floor, Neuadd MeirionnyddHeath ParkCardiffWalesUKCF14 4YS
| | - Mark J Kelly
- Cardiff University School of MedicineSouth East Wales Trials Unit, Institute of Translation, Innovation Methodologies & EngagementNeuadd MeirionnyddHeath ParkCardiffWalesUKCF14 4YS
| | - Alison L Weightman
- Information Services, Cardiff UniversitySupport Unit for Research Evidence (SURE)1st Floor, Neuadd MeirionnyddHeath ParkCardiffWalesUKCF14 4YS
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Ronksley PE, Hemmelgarn BR. Optimizing care for patients with CKD. Am J Kidney Dis 2012; 60:133-8. [PMID: 22480796 DOI: 10.1053/j.ajkd.2012.01.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Accepted: 01/13/2012] [Indexed: 01/13/2023]
Abstract
Care of patients with chronic kidney disease (CKD) is complex and requires a standardized and multidisciplinary approach. A number of strategies have been suggested to improve care for patients with CKD, including the development of clinical practice guidelines and introduction of chronic disease management (CDM) programs. CDM programs represent a proactive approach to care by supporting the physician and patient, with an emphasis on prevention of exacerbations and complications achieved through a coordinated multidisciplinary team. In addition to targeting patients at highest risk, CDM programs also emphasize intensive monitoring and proactive follow-up. The expansion of professional roles may be an important component in ensuring the success of this approach. Although observational studies suggest that specific components of CDM programs may improve care for patients with CKD, further research is needed to evaluate the program component effectiveness in CKD prevention and management. This includes well-conducted randomized trials and long-term follow-up of patients with CKD to assess changes in adverse health outcomes.
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Affiliation(s)
- Paul E Ronksley
- Department of Community Health Sciences, University of Calgary, Alberta, Canada
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Strand H, Parker D. Effects of multidisciplinary models of care for adult pre-dialysis patients with chronic kidney disease: a systematic review. INT J EVID-BASED HEA 2012; 10:53-9. [DOI: 10.1111/j.1744-1609.2012.00253.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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25
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Campbell GA, Bolton WK. Referral and comanagement of the patient with CKD. Adv Chronic Kidney Dis 2011; 18:420-7. [PMID: 22098660 DOI: 10.1053/j.ackd.2011.10.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Revised: 10/18/2011] [Accepted: 10/21/2011] [Indexed: 11/11/2022]
Abstract
CKD is a common condition with well-documented associated morbidity and mortality. Given the substantial disease burden of CKD and the cost of ESRD, interventions to delay progression and decrease comorbidity remain an important part of CKD care. Early referral to nephrologists has been shown to delay progression of CKD. Conversely, late referral has been associated with increased hospitalizations, higher mortality, and worsened secondary outcomes. Late referral to nephrology has been consequent to numerous factors, including the health care system, provider issues, and patient related factors. In addition to timely referral to nephrologists, the optimal modality to provide care for CKD patients has also been evaluated. Multidisciplinary clinics have shown significant improvements in other disease states. Data for the use of these clinics have shown benefit in mortality, progression, and laboratory markers of disease severity. However, studies supporting the use of multidisciplinary clinics in CKD have been mixed. Evidence-based guidelines from groups, including Renal Physicians Association and NKF, provide tools for management of CKD patients by both generalists and nephrologists. Through the use of guidelines, timely referral, and a multidisciplinary approach to care, the ability to provide effective and efficient care for CKD patients can be improved. We present a model to guide a multidisciplinary comanagement approach to providing care to patients with CKD.
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Hayes SL, Mann MK, Morgan FM, Kitcher H, Kelly MJ, Weightman AL. Collaboration between local health and local government agencies for health improvement. Cochrane Database Syst Rev 2011:CD007825. [PMID: 21678371 DOI: 10.1002/14651858.cd007825.pub5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND In many countries, national, regional and local inter- and intra-agency collaborations have been introduced in order to improve health outcomes. Evidence is needed on the effectiveness of locally-developed partnerships which target changes in individual health outcomes and behaviours. OBJECTIVES To evaluate the effects of interagency collaboration between local health and local government agencies on health outcomes. SEARCH STRATEGY Twenty-five databases were searched using a highly sensitive search strategy. 'Snowballing' methods were also used, including expert contact, website searching and reference list follow up. SELECTION CRITERIA Randomized controlled trials (RCTs), controlled clinical trials (CCTs), controlled before-and-after studies (CBAs) and interrupted time series (ITS) where the study reported on interagency collaboration between health and local government agencies. Studies were selected independently in duplicate by two of five authors. DATA COLLECTION AND ANALYSIS From the team of five review authors, two authors independently conducted data extraction and assessed risk of bias for each study. MAIN RESULTS Eleven studies were identified, presenting information on a total of 26,686 participants. Owing to the heterogeneity between studies a narrative synthesis was undertaken. The included studies covered a range of topics. Six studies examined mental health initiatives, of which one study showed health benefit; four showed modest improvement in one or more of the outcomes measured, but no clear overall health gain; and one study showed no evidence of health gain. Two studies were related to lifestyle improvements of which one failed to show health gains for the intervention population, while the other showed more unhealthy lifestyle behaviours persisting in the intervention population. Three studies were related to chronic disease management and all three failed to demonstrate health gains. AUTHORS' CONCLUSIONS Collaboration between local health and local government is commonly considered best practice. However, the review did not identify any reliable evidence that inter‑agency collaboration, compared to standard services, leads to health improvement. A few studies identified component benefits but these were not reflected in overall outcome scores and could have resulted from the use of significant additional resources. Although agencies appear enthusiastic about collaboration, methodological flaws in the primary studies and incomplete implementation of initiatives have prevented the development of a strong evidence base. If these flaws are addressed in future studies (for example by providing greater detail on the implementation of programs, using more robust designs, with integrated process evaluations and measurement of health outcomes) it could provide a better understanding of what might work and why.When updating this review, we will analyse any partnership or process evaluations of our included studies to try to identify markers of success in local collaborative partnerships that could inform policy developments in the future.
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Affiliation(s)
- Sara L Hayes
- on secondment to Department of Public Health and Health Professions, Welsh Assembly Government, 4th Floor North Wing, Welsh Assembly Government, Cathays Park, Cardiff, Wales, UK, CF10 3NQ
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Bayliss EA, Bhardwaja B, Ross C, Beck A, Lanese DM. Multidisciplinary team care may slow the rate of decline in renal function. Clin J Am Soc Nephrol 2011; 6:704-10. [PMID: 21273376 DOI: 10.2215/cjn.06610810] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND OBJECTIVES A multidisciplinary team (MDT) approach to chronic kidney disease (CKD) may help optimize care of CKD and comorbidities. We implemented an MDT quality improvement project for persons with stage 3 CKD and comorbid diabetes and/or hypertension. Our objective was to decrease the rate of decline of GFR. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We used a 4-year historical cohort to compare 1769 persons referred for usual nephrology care versus 233 referred for MDT care within an integrated, not-for-profit Health Maintenance Organization (HMO). Usual care consisted of referral to an outside nephrologist. The MDT consisted of an HMO-based nephrologist, pharmacy specialist, diabetes educator, dietitian, social worker, and nephrology nurse. Both groups received usual primary care. The primary outcome was rate of decline of GFR. Secondary outcomes were LDL, hemoglobin A1c, and BP. RESULTS In multivariate repeated-measures analyses, MDT care was associated with a mean annual decline in GFR of 1.2 versus 2.5 ml/min per 1.73 m(2) for usual care. In stratified analyses, the significant difference in GFR decline persisted only in those who completed their referrals. There were no differences in the secondary outcomes between groups. CONCLUSIONS In this integrated care setting, MDT care resulted in a slower decline in GFR than usual care. This occurred despite a lack of significant differences for secondary disease-specific measures, suggesting that other differences in the MDT population or care process accounted for the slower decline in GFR in the MDT group.
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Affiliation(s)
- Elizabeth A Bayliss
- Kaiser Permanente, Institute for Health Research, 10065 E. Harvard Avenue, Suite 300, Denver, CO 80231, USA.
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Fonouni H, Golriz M, Mehrabi A, Oweira H, Schmied BM, Müller SA, Jarahian P, Tahmasbi Rad M, Esmaeilzadeh M, Tönshoff B, Weitz J, Büchler MW, Zeier M, Schmidt J. The role of an interdisciplinary transplant team on living donation kidney transplantation program. Transplant Proc 2010; 42:137-40. [PMID: 20172299 DOI: 10.1016/j.transproceed.2009.12.038] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
During the last decades, the disparity between the organ supply and the demand for kidney transplantation in Europe has led to consider living donors as a more acceptable option. In the last 7 years, we have established an interdisciplinary supporting transplant team to increase the rate of living donation. After 2001, the new interdisciplinary transplant team consisted of a transplant surgeon, a nephrologist, a pediatrician, a radiologist, a psychologist, a transplant coordinator, and a transplant nurse. We performed a prospective analysis to examine the effect of implementing this team on our living donation program. Demographic data, the annual number of procedures, the duration of waiting, and the cold ischemia time were evaluated among brain-dead and living donors. From January 2002 until December 2008, the number of patients who were annually on the waiting list increased 42% (from 377 to 536 patients). Consequently, the number of the total kidney transplants increased from 81 to 120 with an annual median of 98 cases. By implementing the interdisciplinary transplant team, a significant increase of living kidney donors was observed: from 18 to 42 cases; median = 27). In the last 7 years, a total number of 796 kidney transplants have been performed: 567 from brain-dead and 229 from living donors. In 2001, the waiting list times for recipients who received grafts from brain-dead versus living donors were 1356 versus 615 days respectively. Compared with 2008, the duration on the waiting list decreased significantly for patients receiving a living donor graft, whereas there was a slight increase for the patients in the brain-dead group: brain death versus living donors: 1407 versus 305 days. The interdisciplinary approach has also reduced the cold ischemia time for the living donor recipients: 3 hours and 42 minutes in 2001 versus 2 hours and 50 minutes in 2008. During the last years, by implementing an interdisciplinary transplant team, supporting living donor procedures has produce a gradual increase in the number of kidney transplants from living donors with a remarkable decrease in waiting and cold ischemia times, the latter presumably influencing graft quality.
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Affiliation(s)
- H Fonouni
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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Abstract
Chronic kidney disease is a common disorder and its prevalence is increasing worldwide. Early diagnosis on the basis of presence of proteinuria or reduced estimated glomerular filtration rate could permit early intervention to reduce the risks of cardiovascular events, kidney failure, and death that are associated with chronic kidney disease. In developed countries, screening for the disorder is most efficient when targeted at high-risk groups including elderly people and those with concomitant illness (such as diabetes, hypertension, or cardiovascular disease) or a family history of chronic kidney disease, although the role of screening in developing countries is not yet clear. Effective strategies are available to slow the progression of chronic kidney disease and reduce cardiovascular risk. Treatment of high blood pressure is recommended for all individuals with, or at risk of, chronic kidney disease. Use of angiotensin-converting-enzyme inhibitors or angiotensin-receptor blockers is preferred for patients with diabetic chronic kidney disease or those with the proteinuric non-diabetic disorder. Glycaemic control can help prevent the onset of early stages of chronic kidney disease in individuals with diabetes. Use of statins and aspirin is beneficial for most patients with chronic kidney disease who are at high cardiovascular risk, although research is needed to ascertain how to best prevent cardiovascular disease in this cohort. Models of care that facilitate delivery of the many complex aspects of treatment simultaneously could enhance management, although effects on clinical outcomes need further assessment. Novel clinical methods to better identify patients at risk of progression to later stages of chronic kidney disease, including kidney failure, are needed to target management to high-risk subgroups.
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Affiliation(s)
- Matthew T James
- Department of Medicine, University of Calgary, Calgary, AB, Canada
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WEI SHUYI, CHANG YONGYUAN, MAU LIHWEN, LIN MINGYEN, CHIU HERNGCHIA, TSAI JERCHIA, HUANG CHIHJEN, CHEN HUNGCHUN, HWANG SHANGJYH. Chronic kidney disease care program improves quality of pre-end-stage renal disease care and reduces medical costs. Nephrology (Carlton) 2010; 15:108-15. [DOI: 10.1111/j.1440-1797.2009.01154.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Van Biesen W, Verbeke F, Vanholder R. We don't need no education ... . (Pink Floyd, The Wall ) Multidisciplinary predialysis education programmes: pass or fail? Nephrol Dial Transplant 2009; 24:3277-9. [DOI: 10.1093/ndt/gfp448] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Wu IW, Wang SY, Hsu KH, Lee CC, Sun CY, Tsai CJ, Wu MS. Multidisciplinary predialysis education decreases the incidence of dialysis and reduces mortality--a controlled cohort study based on the NKF/DOQI guidelines. Nephrol Dial Transplant 2009; 24:3426-33. [PMID: 19491379 DOI: 10.1093/ndt/gfp259] [Citation(s) in RCA: 121] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Observational studies have demonstrated that multidisciplinary predialysis education (MPE) improves the post-dialysis outcomes of chronic kidney disease (CKD) patients. However, the beneficial effect of MPE remains unclear in prospective controlled studies. METHODS All CKD patients who visited the outpatient nephrology clinics at two centres of the Chang Gung Memorial Hospital in 2006-07 were enrolled. The incidence of dialysis and mortality were compared between MPE recipients and non-recipients. The content of the MPE was standardized in accordance with the NKF/DOQI guidelines. Prognostic factors for progression to end-stage renal disease (ESRD) and all-cause mortality were analysed by using the Cox proportional hazards model. RESULTS Of 573 patients, 287 received MPE. Dialysis was initiated in 13.9% and 43% of the patients in the MPE and non-MPE groups, respectively (P < 0.001). The mean follow-up period was 11.7 +/- 0.9 months. The overall mortality was 1.7% and 10.1% in the MPE and non-MPE groups, respectively (P < 0.001). Cox regression analysis revealed that diabetes, estimated glomerular filtration rate (eGFR), high-sensitive C-reactive protein (hs-CRP) and MPE assignment were significant independent predictors for progression to ESRD. Independent prognostic factors for mortality included age, diabetes, eGFR, hs-CRP and MPE assignment. CONCLUSIONS MPE based on the NKF/DOQI guidelines may decrease the incidence of dialysis and reduce mortality in late-stage CKD patients.
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Affiliation(s)
- I-Wen Wu
- 1Department of Nephrology, Chang Gung Memorial Hospital, Keelung, Taiwan
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Anderson S, Halter JB, Hazzard WR, Himmelfarb J, Horne FM, Kaysen GA, Kusek JW, Nayfield SG, Schmader K, Tian Y, Ashworth JR, Clayton CP, Parker RP, Tarver ED, Woolard NF, High KP. Prediction, Progression, and Outcomes of Chronic Kidney Disease in Older Adults. J Am Soc Nephrol 2009; 20:1199-209. [DOI: 10.1681/asn.2008080860] [Citation(s) in RCA: 156] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
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Abstract
The number of patients receiving renal replacement therapy in the United Kingdom is rapidly rising. Chronic kidney disease (CKD) is a worldwide public health problem with significant comorbidity and mortality. Several organizational guidelines have been developed in an attempt to identify when appropriate referral to nephrology services should occur; however, many of these guidelines provide conflicting recommendations on referral. Recent surveys suggest that more than 30% of patients with CKD are referred later than is ideal. Late referral of patients with CKD is associated with increased patient morbidity and mortality, increased need for and duration of hospital admission, and increased initial costs of care following commencement of dialysis. Additional benefits of early referral include identifying and treating reversible causes of renal impairment and managing the multiple coexisting conditions associated with CKD. Referral time also affects the choice of treatment modality. Patients and their families should receive sufficient information regarding the nature of their CKD and the options for treatment so that they can make informed decisions concerning their care. Literature addressing when to refer to low-clearance or pre-dialysis clinics is limited. Existing data suggest that such clinics and patient education programs may facilitate improved medical care for patients, greater patient involvement in selection of the mode of dialysis, reduction in the need for “urgent start” dialysis, and improved short-term survival and quality of life after initiation of dialysis. Audit of our pre-dialysis clinic has demonstrated improved patient outcomes, and we view the early-referral service as an essential component of the patient pathway.
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Affiliation(s)
- Susan Ann Heatley
- Central Manchester and Manchester Children's University Hospitals, Manchester, U.K
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Yen M, Huang JJ, Teng HL. Education for patients with chronic kidney disease in Taiwan: a prospective repeated measures study. J Clin Nurs 2008; 17:2927-34. [DOI: 10.1111/j.1365-2702.2008.02348.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Racial and ethnic disparities in health and health care have been documented for over two decades in kidney disease, in a variety of other conditions, across settings, and for different medical and surgical interventions. We now have government reports that track progress on reducing racial disparities, but the pace of progress has been disheartening. The reasons for some of these disparities are known and include biologic, socioeconomic, cultural, and environmental factors as well as system, patient, and provider factors that affect access and quality of medical services. For other disparities, they remain an enigma. Solutions have been slow incoming in large part because we have not held ourselves, and others, accountable for better results. It is time to get serious about equitable health care for all of us.
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Affiliation(s)
- Neil R Powe
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, 2024 E. Monument Street, Suite 2-600, Baltimore, MD 21205, USA.
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Thomas MC. The CARI guidelines. Prevention of progression of kidney disease: pre-dialysis education for patients with chronic kidney disease. Nephrology (Carlton) 2007; 12 Suppl 1:S46-8. [PMID: 17316280 DOI: 10.1111/j.1440-1797.2006.00718.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Merlin C Thomas
- Baker Heart Research Institute, St. Kilda Road Central, PO Box 6492, Melbourne, VIC 8008, Australia.
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Latour CHM, Huyse FJ, de Vos R, Stalman WAB. A method to provide integrated care for complex medically ill patients: The INTERMED. Nurs Health Sci 2007; 9:150-7. [PMID: 17470190 DOI: 10.1111/j.1442-2018.2007.00292.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A growing number of nursing subspecializations have been developed in recent decades. Topics of concern are that care is not tailored to cope with the growing number of patients with more than one chronic disease, there is an increase in co-ordination problems in the care that is provided for this group of complex patients, and the care for these complex patients is extremely fragmented. The assessment of health risks resulting in co-ordinated care with effective communication is vital for multimorbid patients. Our aim is to describe a systematic approach (the INTERMED [IM] method) to identify complex patients who are in need of integrated care and its applicability to the nursing process. We demonstrate the ability of the IM method to quantify, weigh, and classify the complexity of problems. The method is applied in Europe and will be started in the USA in a pharmacy program. The IM is presented as a decision-support system for multidisciplinary teams with nurse co-ordinators.
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Affiliation(s)
- Cornelia H M Latour
- Psychiatric Consultation and Liaison Service, Vrije University Medical Center, The Netherlands
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Latour CHM, Bosmans JE, van Tulder MW, de Vos R, Huyse FJ, de Jonge P, van Gemert LAM, Stalman WAB. Cost-effectiveness of a nurse-led case management intervention in general medical outpatients compared with usual care: an economic evaluation alongside a randomized controlled trial. J Psychosom Res 2007; 62:363-70. [PMID: 17324688 DOI: 10.1016/j.jpsychores.2006.10.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2005] [Revised: 10/23/2006] [Accepted: 10/24/2006] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The objective of this study was to evaluate the cost-effectiveness of a nurse-led, home-based, case-management intervention (NHI) after hospital discharge in addition to usual care. METHODS Economic evaluation alongside a randomized controlled trial after being discharged home with 24 weeks of follow-up. Patients discharged to their home from a general hospital were randomly assigned to NHI or usual care. Clinical outcomes were frequency of emergency readmissions, quality of life, and psychological functioning. Direct costs were measured by means of cost diaries kept by the patients and information obtained from the patients' pharmacists. RESULTS A total of 208 patients were randomized, 61 patients dropped out, and 26 had incomplete data, leaving a total of 121 patients included in the final analysis. There were no statistically significant differences in emergency readmissions, quality of life, and psychological functioning. There was a substantial difference in total costs between the NHI group and the control group (4286 Euro; 95% CI, -41; 8026), but this difference was not statistically significant. CONCLUSION NHI is not a cost-effective intervention. We do not recommend the implementation of this intervention in populations that do not consist of severely vulnerable and complex patients. Future studies should include complexity assessment on inclusion and evaluate the effectiveness and cost-effectiveness of this intervention in patients with more complex profiles.
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Affiliation(s)
- Corine H M Latour
- Psychiatric Consultation and Liaison Service, VU University Medical Center, Amsterdam, The Netherlands.
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Hemmelgarn BR, Manns BJ, Zhang J, Tonelli M, Klarenbach S, Walsh M, Culleton BF. Association between Multidisciplinary Care and Survival for Elderly Patients with Chronic Kidney Disease. J Am Soc Nephrol 2007; 18:993-9. [PMID: 17267742 DOI: 10.1681/asn.2006080860] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The effectiveness of multidisciplinary care (MDC) in improving health outcomes for patients with chronic kidney disease (CKD) is uncertain. This study sought to determine the association among MDC, survival, and risk for hospitalization among elderly outpatients with CKD. A total of 6978 patients who were 66 yr and older and had CKD were identified between July 1 and December 31, 2001, and followed to December 31, 2004; 187 (2.7%) were followed in an MDC clinic. Logistic regression was used to determine the propensity score (probability of MDC) for each patient, and MDC and non-MDC patients then were matched 1:1 on the basis of their score. A Cox model was used to determine the association between MDC and risk for death and hospitalization. After adjustment for age, gender, baseline GFR, diabetes, and comorbidity score, there was a 50% reduction in the risk for death for the MDC compared with the non-MDC group (hazard ratio [HR] 0.50; 95% confidence interval [CI] 0.35 to 0.71). There was no difference in the risk for all-cause (HR 0.83; 95% CI 0.64 to 1.06) or cardiovascular-specific hospitalization (HR 0.76; 95% CI 0.54 to 1.06) for the MDC compared with the non-MDC group. In conclusion, it was found that MDC was associated with a significant reduction in the risk for all-cause mortality and, although not statistically significant, a trend toward a reduction in risk for all-cause and cardiovascular-specific hospitalizations. The benefits of MDC and an assessment of their economic impact should be tested in a randomized, controlled trial.
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Affiliation(s)
- Brenda R Hemmelgarn
- Department of Medicine, Community Health Schiences, University of Calgary, Calgary, Canada.
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Progress in retarding the progression of advanced chronic kidney disease: Grounds for optimism. Kidney Int 2006. [DOI: 10.1038/sj.ki.5001976] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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43
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Latour CHM, de Vos R, Huyse FJ, de Jonge P, van Gemert LAM, Stalman WAB. Effectiveness of Post-Discharge Case Management in General-Medical Outpatients: A Randomized, Controlled Trial. PSYCHOSOMATICS 2006; 47:421-9. [PMID: 16959931 DOI: 10.1176/appi.psy.47.5.421] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
This study was initiated to determine the impact of post-discharge, nurse-led, home-based case management intervention on the number of emergency readmissions, level of care utilization, quality of life, and psychological functioning. Patients discharged home from a general hospital (N=147) were randomly assigned to usual care or nurse-led, home-based, case management intervention. During the 24 weeks of follow-up, no difference between the two groups was found for readmission, care utilization, quality of life, or psychological functioning. Patients in the control group tended to move sooner to non-independent living accommodation than patients in the nurse-led, home-based, case management intervention group.
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Affiliation(s)
- Corine H M Latour
- Psychiatric Consultation and Liaison Service / Rm. 2 D 22, VU University Medical Center, P.O. Box 7057 1007, MB Amsterdam, the Netherlands.
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44
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Herget-Rosenthal S, Quellmann T, Linden C, Reinhardt W, Philipp T, Kribben A. Management of advanced chronic kidney disease in primary care - current data from Germany. Int J Clin Pract 2006; 60:941-8. [PMID: 16780569 DOI: 10.1111/j.1742-1241.2006.01028.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The quality of chronic kidney disease (CKD) care and the control of CKD progression factors and of comorbid conditions according to current recommendations in primary care were investigated in this retrospective cohort study of 127 consecutive CKD patients. CKD was advanced (glomerular filtration rate 21 +/- 10 ml/min). Fifty-seven per cent of patients had been evaluated to clarify CKD aetiology. Blood pressure was substantially elevated (148 +/- 20/83 +/- 11 mmHg) and only 39% of patients achieved target blood pressure levels. At a mean HbA(1c) of 6.5 +/- 1.1%, glycaemic control was good in 63% of diabetics. Mean haemoglobin was 10.8 +/- 1.8 g/dl, and anaemia was adequately controlled in 49%. In 42% the management of bone disease and in 80% the nutritional status was sufficient. Angiotensin converting enzyme inhibitors or angiotensin-2-receptor blockers was used in 59% of patients with diabetic nephropathy or proteinuria above 1 g/day. High-total quality of care was only achieved in 35% which suggests that the management of advanced CKD in primary care is suboptimal.
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45
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Beach MC, Gary TL, Price EG, Robinson K, Gozu A, Palacio A, Smarth C, Jenckes M, Feuerstein C, Bass EB, Powe NR, Cooper LA. Improving health care quality for racial/ethnic minorities: a systematic review of the best evidence regarding provider and organization interventions. BMC Public Health 2006; 6:104. [PMID: 16635262 PMCID: PMC1525173 DOI: 10.1186/1471-2458-6-104] [Citation(s) in RCA: 116] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2005] [Accepted: 04/24/2006] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Despite awareness of inequities in health care quality, little is known about strategies that could improve the quality of healthcare for ethnic minority populations. We conducted a systematic literature review and analysis to synthesize the findings of controlled studies evaluating interventions targeted at health care providers to improve health care quality or reduce disparities in care for racial/ethnic minorities. METHODS We performed electronic and hand searches from 1980 through June 2003 to identify randomized controlled trials or concurrent controlled trials. Reviewers abstracted data from studies to determine study characteristics, results, and quality. We graded the strength of the evidence as excellent, good, fair or poor using predetermined criteria. The main outcome measures were evidence of effectiveness and cost of strategies to improve health care quality or reduce disparities in care for racial/ethnic minorities. RESULTS Twenty-seven studies met criteria for review. Almost all (n = 26) took place in the primary care setting, and most (n = 19) focused on improving provision of preventive services. Only two studies were designed specifically to meet the needs of racial/ethnic minority patients. All 10 studies that used a provider reminder system for provision of standardized services (mostly preventive) reported favorable outcomes. The following quality improvement strategies demonstrated favorable results but were used in a small number of studies: bypassing the physician to offer preventive services directly to patients (2 of 2 studies favorable), provider education alone (2 of 2 studies favorable), use of a structured questionnaire to assess adolescent health behaviors (1 of 1 study favorable), and use of remote simultaneous translation (1 of 1 study favorable). Interventions employing more than one main strategy were used in 9 studies with inconsistent results. There were limited data on the costs of these strategies, as only one study reported cost data. CONCLUSION There are several promising strategies that may improve health care quality for racial/ethnic minorities, but a lack of studies specifically targeting disease areas and processes of care for which disparities have been previously documented. Further research and funding is needed to evaluate strategies designed to reduce disparities in health care quality for racial/ethnic minorities.
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Affiliation(s)
- Mary Catherine Beach
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland, USA
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Phoebe R. Berman Bioethics Institute, Johns Hopkins University, Baltimore, Maryland, USA
| | - Tiffany L Gary
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Eboni G Price
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Karen Robinson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Aysegul Gozu
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ana Palacio
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Carole Smarth
- Robert Wood Johnson Clinical Scholars Program, Johns Hopkins University, USA
| | - Mollie Jenckes
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Carolyn Feuerstein
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eric B Bass
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Neil R Powe
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland, USA
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Robert Wood Johnson Clinical Scholars Program, Johns Hopkins University, USA
| | - Lisa A Cooper
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland, USA
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Jones C, Roderick P, Harris S, Rogerson M. An evaluation of a shared primary and secondary care nephrology service for managing patients with moderate to advanced CKD. Am J Kidney Dis 2006; 47:103-14. [PMID: 16377391 DOI: 10.1053/j.ajkd.2005.09.020] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2005] [Accepted: 09/20/2005] [Indexed: 12/13/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) is common, and nephrology services may not cope with the comprehensive referral of patients with CKD. We evaluated a shared primary and secondary care nephrology scheme, hypothesizing that some patients with less progressive moderate to advanced CKD can be identified and safely managed without attending the renal unit. METHODS A retrospective review of 949 new referrals with stages 3 to 5 CKD managed in either the hospital nephrology clinic (HC) or the shared care scheme (SCS), in which nephrologists review patients remotely by using regular biochemical tests and clinical data recorded in primary care. RESULTS Two hundred sixty-six patients (28%) were enrolled in the SCS and 683 patients (72%) were managed solely in the HC. Median time to entering the SCS was 111 days (interquartile range, 0 to 328 days). Baseline factors independently predictive of enrollment in the SCS were increasing age, greater glomerular filtration rate (GFR) and serum albumin levels, and no diabetic nephropathy. Few SCS patients did not attend reviews. Forty-one patients (15%) required recall to the HC, mostly because of a decline in GFR. Beneficial changes were seen in blood pressure levels and prescribing of angiotensin-system inhibitors from first referral to 3 years in all patients. Those enrolled in the SCS had good prognosis, with a lower risk for death or renal replacement therapy than the HC group after adjustment for age, sex, GFR, diabetic nephropathy, and vascular disease (hazard ratio, 0.64; 95% confidence interval, 0.38 to 0.89; P = 0.003). CONCLUSION In this setting, it was possible to select nearly 30% of patients with stages 3 to 5 CKD for management in the SCS. More than half enrolled within 4 months of nephrology referral. Systematic surveillance was effective, and most patients remained stable, with few progressing to renal replacement therapy or death.
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Affiliation(s)
- Chris Jones
- Department of Public Health Sciences and Medical Statistics, University of Southampton, Southampton, UK.
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47
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Komenda P, Levin A. Analysis of cardiovascular disease and kidney outcomes in multidisciplinary chronic kidney disease clinics: complex disease requires complex care models. Curr Opin Nephrol Hypertens 2006; 15:61-6. [PMID: 16340668 DOI: 10.1097/01.mnh.0000191911.57657.35] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW Chronic kidney disease is recognized as being highly prevalent in the population, and associated with morbidity and mortality relative to the general population. The complexity of patients and the multiplicity of interventions required to maintain health has forced clinicians to develop different models of healthcare delivery. This publication reviews the current literature on specific interventions to reduce progression of chronic kidney disease and cardiovascular disease, and studies the examination of outcomes of patients exposed to different healthcare delivery models. Specifically we examine the rationale and outcomes of those seen in multidisciplinary clinics. RECENT FINDINGS Current evidence supports the use of rennin-angiotensin system blockers, reduction of blood pressure and proteinuria and phosphate control. Additional less robust studies support the need for attention to anemia, hyperparathryoidism, and other more "kidney specific" risk factors. The attendance of identified chronic kidney disease patients at multidisciplinary clinics appears to improve survival once dialysis is started. Despite aggressive management, not all patients are able to meet clinical targets associated with improved outcomes. SUMMARY The recognition of the complexity of chronic kidney disease care and the need to develop and test models of care in addition to the single interventions is a challenge for both researchers and clinicians. Current data support the use of multidisciplinary clinics in improving outcomes of referred patients. Future research will help to refine and define appropriate care models for this growing chronic kidney disease population.
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Affiliation(s)
- Paul Komenda
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
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48
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Patel UD, Young EW, Ojo AO, Hayward RA. CKD Progression and Mortality Among Older Patients With Diabetes. Am J Kidney Dis 2005; 46:406-14. [PMID: 16129201 DOI: 10.1053/j.ajkd.2005.05.027] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2005] [Accepted: 05/26/2005] [Indexed: 11/11/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) is clearly associated with an increased risk for adverse outcomes; however, the cumulative impact of renal and cardiac complications in high-risk populations is not known. In addition, little is known about patterns of nephrology care in patients with CKD. METHODS We conducted a retrospective longitudinal cohort study assessing CKD prevalence and progression, associations with all-cause mortality, and variations in patterns of nephrology consultation in older patients with diabetes in a vertically integrated health care system. RESULTS A total of 12,570 patients within a 7-Veterans Affairs hospital service network in 1998 to 1999 were identified by means of computerized records. Nearly half (48%) were affected with CKD; most had mild to moderate CKD. After an observation period of 3 years, mortality rates in those unaffected with CKD were high (4.7 deaths/100 person-years) and increased substantially with progressive CKD (eg, 20.1 deaths/100 person-years with an estimated glomerular filtration rate [GFR] of 15 to 29 mL/min/1.73 m2 [0.25 to 0.48 mL/s/1.73 m2]). Only 7.2% of patients with CKD had a nephrology visit during the entire 5-year study period. Although visits increased with more advanced CKD, only 32% of patients with an estimated GFR of 15 to 29 mL/min/1.73 m2 had been seen in a nephrology clinic. We also found that nephrology referrals were driven preferentially by elevations in serum creatinine levels, rather than low GFRs. CONCLUSION Many in this cohort of older patients with diabetes are affected with CKD. Mortality rates are high, and mortality risks associated with CKD amplify those of other risk factors. Nephrology visits are low and may represent an unexploited resource for improving CKD management. Underrecognition of CKD likely is related to overestimation of kidney function by relying on serum creatinine level in elderly patients.
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Affiliation(s)
- Uptal D Patel
- Veterans Affairs Health Services Research and Development Center of Excellence, VA Ann Arbor Healthcare System, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA.
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49
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Minutolo R, De Nicola L, Zamboli P, Chiodini P, Signoriello G, Toderico C, Arfè G, Boschi G, Brancati C, Iaccarino P, Conte G. Management of Hypertension in Patients With CKD: Differences Between Primary and Tertiary Care Settings. Am J Kidney Dis 2005; 46:18-25. [PMID: 15983953 DOI: 10.1053/j.ajkd.2005.03.019] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Although most patients with moderate chronic kidney disease (CKD) are managed exclusively in primary care (PC), no data on blood pressure (BP) control in this setting are available. We compared hypertension management in patients with CKD followed up in PC and nephrology tertiary care (TC). METHODS We studied hypertensive patients with estimated glomerular filtration rates (eGFRs) of 15 to 60 mL/min/1.73 m2 (0.25 to 1.00 mL/s) exclusively followed up for at least 1 year in PC (n = 259) or TC (n = 186). RESULTS PC compared with TC patients were characterized by older age (73 +/- 10 versus 65 +/- 14 years; P < 0.0001), greater prevalences of previous cardiovascular events (59% versus 32%; P < 0.0001) and diabetes (36% versus 23%; P = 0.005), and slightly greater eGFRs (37 +/- 10 versus 34 +/- 11 mL/min/1.73 m2 ; P = 0.005). They showed higher BP levels (143 +/- 15/82 +/- 7 versus 136 +/- 18/78 +/- 11 mm Hg; P < 0.0001), with a lower prevalence of BP target (5.8% [95% confidence interval (CI), 2.9 to 8.6] versus 21.5% [95% CI, 15.6 to 27.4]; P < 0.0001). The risk for not achieving BP target in PC was 2.6 times greater, independently from age, sex, diabetes, and eGFR. Fewer antihypertensive drugs were prescribed in PC (1.9 +/- 1.1 versus 2.5 +/- 1.1; P < 0.0001). In both groups, inhibitors of the renin-angiotensin system were the most frequently prescribed drugs (>84%), followed by diuretics (50%). However, family physicians almost exclusively prescribed hydrochlorothiazide, whereas nephrologists preferentially prescribed furosemide, administered at a higher dose than in PC (47 +/- 41 versus 28 +/- 21 mg/d; P = 0.004). CONCLUSION Control of CKD-related hypertension is significantly worse in PC despite a greater cardiovascular risk. Barriers to optimal BP control likely are represented by a low number of drugs and inadequate diuretic therapy.
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Affiliation(s)
- Roberto Minutolo
- Department of Nephrology, Second University of Naples, Naples, Italy.
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50
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Tierney WM, Overhage JM, Murray MD, Harris LE, Zhou XH, Eckert GJ, Smith FE, Nienaber N, McDonald CJ, Wolinsky FD. Can computer-generated evidence-based care suggestions enhance evidence-based management of asthma and chronic obstructive pulmonary disease? A randomized, controlled trial. Health Serv Res 2005; 40:477-97. [PMID: 15762903 PMCID: PMC1361152 DOI: 10.1111/j.1475-6773.2005.00368.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Translation of evidence-based guidelines into clinical practice has been inconsistent. We performed a randomized, controlled trial of guideline-based care suggestions delivered to physicians when writing orders on computer workstations. STUDY SETTING Inner-city academic general internal medicine practice. STUDY DESIGN Randomized, controlled trial of 246 physicians (25 percent faculty general internists, 75 percent internal medicine residents) and 20 outpatient pharmacists. We enrolled 706 of their primary care patients with asthma or chronic obstructive pulmonary disease. Care suggestions concerning drugs and monitoring were delivered to a random half of the physicians and pharmacists when writing orders or filling prescriptions using computer workstations. A 2 x 2 factorial randomization of practice sessions and pharmacists resulted in four groups of patients: physician intervention, pharmacist intervention, both interventions, and controls. DATA EXTRACTION/COLLECTION METHODS: Adherence to the guidelines and clinical activity was assessed using patients' electronic medical records. Health-related quality of life, medication adherence, and satisfaction with care were assessed using telephone questionnaires. PRINCIPAL FINDINGS During their year in the study, patients made an average of five scheduled primary care visits. There were no differences between groups in adherence to the care suggestions, generic or condition-specific quality of life, satisfaction with physicians or pharmacists, medication compliance, emergency department visits, or hospitalizations. Physicians receiving the intervention had significantly higher total health care costs. Physician attitudes toward guidelines were mixed. CONCLUSIONS Care suggestions shown to physicians and pharmacists on computer workstations had no effect on the delivery or outcomes of care for patients with reactive airways disease.
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Affiliation(s)
- William M Tierney
- Department of Medicine, Indiana University School of Medicine, M200-OPW, Wishard Memorial Hospital, 1001 West 10th St., Indianapolis, IN 46202, USA
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