Cost-effectiveness of multidisciplinary care in mild to moderate chronic kidney disease in the United States: A modeling study

Examining chronic kidney disease screening frequency among diabetics: a POMDP approach

Forty percent of diabetics will develop chronic kidney disease (CKD) in their lifetimes. However, as many as 50% of these CKD cases may go undiagnosed. We developed screening recommendations stratified by age and previous test history for individuals with diagnosed diabetes and unknown proteinuria status by race and gender groups. To do this, we used a Partially Observed Markov Decision Process (POMDP) to identify whether a patient should be screened at every three-month interval from ages 30-85. Model inputs were drawn from nationally-representative datasets, the medical literature, and a microsimulation that integrates this information into group-specific disease progression rates. We implement the POMDP solution policy in the microsimulation to understand how this policy may impact health outcomes and generate an easily-implementable, non-belief-based approximate policy for easier clinical interpretability. We found that the status quo policy, which is to screen annually for all ages and races, is suboptimal for maximizing expected discounted future net monetary benefits (NMB). The POMDP policy suggests more frequent screening after age 40 in all race and gender groups, with screenings 2-4 times a year for ages 61-70. Black individuals are recommended for screening more frequently than their White counterparts. This policy would increase NMB from the status quo policy between $1,000 to  $8,000 per diabetic patient at a willingness-to-pay of $150,000 per quality-adjusted life year (QALY).

Implementing a Formalized Risk-Based Approach to Determine Candidacy for Multidisciplinary CKD Care: A Descriptive Cohort Study

Background

The kidney failure risk equation (KFRE) can be used to predict progression to end-stage kidney disease in a clinical setting.

Objective

Evaluate implementation of a formalized risk-based approach in nephrologists' outpatient clinics and multidisciplinary chronic kidney disease (CKD) clinics to determine candidacy for multidisciplinary care, and the impact of CKD care selection on clinical outcomes.

Design

Population-based descriptive cohort study.

Setting

Alberta Kidney Care South.

Patients

Adults attending or considered for a multidisciplinary CKD clinic between April 1, 2017, and March 31, 2019.

Measurements

Exposure-The course of CKD care assigned by the nephrologist: management at multidisciplinary CKD clinic; management by a nephrologist or primary care physician. Primary Outcome-CKD progression, defined as commencement of kidney replacement therapy (KRT). Secondary Outcomes-Death, emergency department visits, and hospitalizations.

Methods

We linked operational data from the clinics (available until March 31, 2019) with administrative health and laboratory data (available until March 31, 2020). Comparisons among patient groups, courses of care, and clinical settings with negative binomial regression count models and calculated unadjusted and fully adjusted incidence rate ratios. For the all-cause death outcome, we used Cox survival models to calculate unadjusted and fully adjusted hazard ratios.

Results

Of the 1748 patients for whom a KFRE was completed, 1347 (77%) remained in or were admitted to a multidisciplinary CKD clinic, 310 (18%) were managed by a nephrologist only, and 91 (5%) were referred back for management by their primary care physician. There was a much higher kidney failure risk among patients who remained at or were admitted to a multidisciplinary CKD clinic (median 2-year risk of 34.7% compared with 3.6% and 0.8% who remained with a nephrologist or primary care physician, respectively). None of the people managed by their primary care physician alone commenced KRT, while only 2 (0.6%) managed by a nephrologist without multidisciplinary CKD care commenced KRT. The rates of emergency department visits, hospitalizations, and death were lower in those assigned to management outside the multidisciplinary CKD clinics when compared with those managed in the multidisciplinary care setting.

Limitations

The follow-up period may not have been long enough to determine outcomes, and potentially limited generalizability given variability of care in multidisciplinary clinics.

Conclusions

Our findings indicate that a portion of patients can be directed to less resource-intensive care without a higher risk of adverse events.

Trial registration

Not applicable.

VA-Based Peritoneal Dialysis Program Feasibility Considerations and Process Outline

Background

Home dialysis utilization is lower among veterans than in the general US population. Several sociodemographic factors and comorbidities contribute to peritoneal dialysis (PD) underutilization. In 2019, the Veterans Health Administration (VHA) Kidney Disease Program Office convened a PD workgroup to address this concern.

Observations

The PD workgroup was explicitly concerned by the limited availability of PD within the VHA, which frequently requires veterans to transition kidney disease care from US Department of Veterans Affairs medical centers (VAMCs) to non-VHA facilities when they progress from chronic kidney disease to end-stage kidney disease, causing fragmentation of care. Since the administrative requirements and infrastructure of VAMCs vary, the workgroup focused its deliberations on synthesizing a standard process for evaluating the feasibility and establishing a new PD program within any individual VAMC. A 3-phased approach was envisioned, beginning with ascertainment of prerequisites, leading to an examination of the clinical and financial feasibility through the process of data gathering and synthesis, culminating in a business plan that translates the previous 2 steps into an administrative document necessary for obtaining VHA approvals.

Conclusions

VAMCs can use the guide presented here to improve therapeutic options for veterans with kidney failure by establishing a new or restructured PD program.

Cost-Effectiveness Analysis of Nefecon versus Best Supportive Care for People with Immunoglobulin A Nephropathy (IgAN) in the United States

Purpose

To estimate the cost-effectiveness of Nefecon in addition to the best supportive care (BSC) vs BSC in a hypothetical cohort of commercially insured adult patients with primary immunoglobulin A nephropathy (IgAN) from a United States (US) societal perspective.

Methods

A lifetime horizon, semi-Markov model was developed that consisted of nine health states: chronic kidney disease (CKD) stage 1, 2, 3a, 3b, 4, end-stage renal disease (ESRD) with dialysis, ESRD without dialysis, post-kidney transplant, and death. Health state occupancy was estimated from individual patient-level data from the Phase 3 randomized controlled trial NefIgArd Part A (NCT03643965). Additional scenarios evaluated the impact of varying the time horizon, discounting, costs included, rounds of treatment, and the method used to calculate transition probabilities.

Results

In the deterministic base case analysis over a lifetime horizon, Nefecon plus BSC (hereafter Nefecon) had an incremental cost of $3,810 vs BSC. Nefecon resulted in a mean survival gain of 0.247 quality-adjusted life years (QALYs), 0.195 life years (LYs), and 0.244 equal value life years (evLYs) vs BSC alone - this resulted in incremental cost-effectiveness ratios (ICERs) of $15,428 per QALY, $19,502 per LY, and $15,611 per evLY gained. Probabilistic sensitivity analyses estimated that with willingness to pay thresholds of $100,000, $150,000, and $250,000 per QALY gained, Nefecon would be cost-effective over BSC in 66.70%, 75.02%, and 86.82% of cases, respectively. In the scenario analysis, Nefecon remained cost-effective with 4 rounds of treatment.

Conclusion

Nefecon was associated with LY and QALY gains vs BSC, with an incremental cost of $3,810. Based on these values, with a willingness to pay threshold of $100,000 per QALY gained, Nefecon was found to be a cost-effective treatment for US adults with primary IgAN.

APOL1 Genotype, Proteinuria, and the Risk of Kidney Failure: A Secondary Analysis of the AASK (African American Study of Kidney Disease and Hypertension) and CRIC (Chronic Renal Insufficiency Cohort) Studies

Rationale & Objective

Patients with a high-risk Apolipoprotein L1 (APOL1) genotype are more likely to develop chronic kidney disease and kidney failure. It is unclear whether this increased risk is entirely mediated by the development of proteinuria.

Study Design

Retrospective observational study of the African American Study of Kidney Disease and Hypertension cohort and Chronic Renal Insufficiency Cohort.

Exposures & Predictors

Self-identified race (Black/non-Black) and presence of high-risk APOL1 genotype. The primary model was adjusted for age, sex, diabetes, estimated glomerular filtration rate, and urinary protein-creatinine ratio.

Outcomes

Time to kidney failure defined as time to dialysis or transplantation.

Analytical Approach

We used Cox proportional hazard models to study how proteinuria mediates the association between APOL1 and kidney failure. We modeled proteinuria at baseline and as a time-varying covariate.

Results

A high-risk APOL1 genotype was associated with a significantly higher risk of kidney failure, even for patients with minimal proteinuria (HR, 1.87; 95% CI, 1.23-2.84). The association was not significant among patients with high proteinuria (HR, 1.22; 95% CI, 0.93-1.61). When modeling proteinuria as a time-varying covariate, a high-risk APOL1 genotype was associated with higher kidney failure risk even among patients who never developed proteinuria (HR, 2.04; 95% CI, 1.10-3.77). Compared to non-Black patients, Black patients without the high-risk genotype did not have higher risk of kidney failure (HR, 0.96; 95% CI, 0.85-1.10).

Limitations

Two datasets were combined to increase statistical power. Limited generalizability beyond the study cohorts. Residual confounding common to observational studies.

Conclusions

A high-risk APOL1 genotype is significantly associated with increased kidney failure risk, especially among patients without baseline proteinuria. Although our results suggest that the risk is partially mediated through proteinuria, higher kidney failure risk was present even among patients who never developed proteinuria. Providers should consider screening for the high-risk APOL1 genotype, especially among Black patients without proteinuria in populations with chronic kidney disease.

Adherence to multidisciplinary care in a prospective chronic kidney disease cohort is associated with better outcomes

INTRODUCTION

The Renal Healthcare Program Uruguay (NRHP-UY) is a national, multidisciplinary program that provides care to chronic kidney disease (CKD) patients. In this study, we report the global results of CKD patient outcomes and a comparison between those treated at the NRHP-UY Units, with those patients who were initially included in the program but did not adhere to follow up.

METHODS

A cohort of not-on dialysis CKD patients included prospectively in the NRHP-UY between October 1st 2004 and September 30th 2017 was followed-up until September 30th 2019. Two groups were compared: a) Nephrocare Group: Patients who had at least one clinic visit during the first year on NRHP-UY (n = 11174) and b) Non-adherent Group: Patients who were informed and accepted to be included but had no subsequent data registered after admission (n = 3485). The study was approved by the Ethics Committee and all patients signed an informed consent. Outcomes were studied with Logistic and Cox´s regression analysis, Fine and Gray competitive risk and propensity-score matching tests.

RESULTS

14659 patients were analyzed, median age 70 (60-77) years, 56.9% male. The Nephrocare Group showed improved achievement of therapeutic goals, ESKD was more frequent (HR 2.081, CI 95%1.722-2.514) as planned kidney replacement therapy (KRT) start (OR 2.494, CI95% 1.591-3.910), but mortality and the combined event (death and ESKD) were less frequent (HR 0.671, CI95% 0.628-0.717 and 0.777, CI95% 0.731-0.827) (p = 0.000) compared to the Non-adherent group. Results were similar in the propensity-matched group: ESKD (HR 2.041, CI95% 1.643-2.534); planned kidney replacement therapy (KRT) start (OR 2.191, CI95% 1.322-3.631) death (HR 0.692, CI95% 0.637-0.753); combined event (HR 0.801, CI95% 0.742-0.865) (p = 0.000).

CONCLUSION

Multidisciplinary care within the NRHP-UY is associated with timely initiation of KRT and lower mortality in single outcomes, combined analysis, and propensity-matched analysis.

Multidisciplinary amyloidosis care in the era of personalized medicine

Amyloidosis refers to a group of conditions where abnormal protein-or amyloid-deposits in tissues or organs, often leading to organ malfunction. Amyloidosis affects nearly any organ system, but especially the heart, kidneys, liver, peripheral nervous system, and gastrointestinal tract. Neuromuscular deficits comprise some of its ubiquitous manifestations. Amyloidosis can be quite challenging to diagnose given its clinical heterogeneity and multi-system nature. Early diagnosis with accurate genetic and serologic subtyping is key for effective management and prevention of organ decline. In this review, we highlight the value of a multidisciplinary comprehensive amyloidosis clinic. While such a model exists at numerous clinical and research centers across the globe, the lack of more widespread adoption of such a model remains a major hindrance to the timely diagnosis of amyloidosis. Such a multidisciplinary care model allows for the timely and effective diagnosis of amyloidosis, be it acquired amyloid light amyloidosis (AL), hereditary transthyretin amyloidosis (hATTR), or wild type amyloidosis (TTR-wt), especially in the current era of personalized genomic medicine. A multidisciplinary clinic optimizes the delivery of singular or combinatorial drug therapies, depending on amyloid type, fibril deposition location, and disease progression. Such an arrangement also helps advance research in the field. We present our experience at The Ohio State University, as one example out of many, to highlight the centrality of a multi-disciplinary clinic in amyloidosis care.

Machine Learning Models for the Prediction of Renal Failure in Chronic Kidney Disease: A Retrospective Cohort Study

This study assessed the feasibility of five separate machine learning (ML) classifiers for predicting disease progression in patients with pre-dialysis chronic kidney disease (CKD). The study enrolled 858 patients with CKD treated at a veteran’s hospital in Taiwan. After classification into early and advanced stages, patient demographics and laboratory data were processed and used to predict progression to renal failure and important features for optimal prediction were identified. The random forest (RF) classifier with synthetic minority over-sampling technique (SMOTE) had the best predictive performances among patients with early-stage CKD who progressed within 3 and 5 years and among patients with advanced-stage CKD who progressed within 1 and 3 years. Important features identified for predicting progression from early- and advanced-stage CKD were urine creatinine and serum creatinine levels, respectively. The RF classifier demonstrated the optimal performance, with an area under the receiver operating characteristic curve values of 0.96 for predicting progression within 5 years in patients with early-stage CKD and 0.97 for predicting progression within 1 year in patients with advanced-stage CKD. The proposed method resulted in the optimal prediction of CKD progression, especially within 1 year of advanced-stage CKD. These results will be useful for predicting prognosis among patients with CKD.

Cost-Effectiveness of Dapagliflozin for Non-diabetic Chronic Kidney Disease

BACKGROUND

In the USA, chronic kidney disease (CKD) affects 1 in 7 adults and costs $100 billion annually. The DAPA-CKD trial found dapagliflozin, a sodium glucose co-transporter 2 (SGLT2) inhibitor, to be effective in reducing CKD progression and mortality in patients with diabetic and non-diabetic CKD. Currently, SGLT2 inhibitors are not considered standard of care for patients with non-diabetic CKD.

OBJECTIVE

Determine the cost-effectiveness of adding dapagliflozin to standard management of patients with non-diabetic CKD.

DESIGN

Markov model with lifetime time horizon and US healthcare sector perspective.

PATIENTS

Patients with non-diabetic CKD INTERVENTION: Dapagliflozin plus standard care versus standard care only.

MAIN MEASURES

Quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs), all discounted at 3% annually; total incidence of kidney failure on kidney replacement therapy; average years on kidney replacement therapy.

KEY RESULTS

Adding dapagliflozin to standard care improved life expectancy by 2 years, increased discounted QALYS (from 6.75 to 8.06), and reduced the total incidence of kidney failure on kidney replacement therapy (KRT) (from 17.4 to 11.0%) and average years on KRT (from 0.77 to 0.43) over the lifetime of the cohort. Dapagliflozin plus standard care was more effective than standard care alone while increasing lifetime costs (from $245,900 to $324,8900, or $60,000 per QALY gained). Results were robust to variations in assumptions about dapagliflozin's efficacy over time and by CKD stage, added costs of kidney replacement therapy, and expected population annual CKD progression rates and sensitive to the cost of dapagliflozin. The net 1-year budgetary implication of treating all US patients with non-diabetic CKD could be up to $21 billion.

CONCLUSIONS

Dapagliflozin improved life expectancy and reduced progression of CKD, the proportion of patients requiring kidney replacement therapy, and time on kidney replacement therapy in patients with non-diabetic CKD. Use of dapagliflozin meets conventional criteria for cost-effectiveness.

Clinical Trial Considerations in Developing Treatments for Early Stages of Common, Chronic Kidney Diseases: A Scientific Workshop Cosponsored by the National Kidney Foundation and the US Food and Drug Administration

In the past decade, advances in the validation of surrogate end points for chronic kidney disease (CKD) progression have heightened interest in evaluating therapies in early CKD. In December 2020, the National Kidney Foundation sponsored a scientific workshop in collaboration with the US Food and Drug Administration (FDA) to explore patient, provider, and payor perceptions of the value of treating early CKD. The workshop reviewed challenges for trials in early CKD, including trial designs, identification of high-risk populations, and cost-benefit and safety considerations. Over 90 people representing a range of stakeholders including experts in clinical trials, nephrology, cardiology and endocrinology, patient advocacy organizations, patients, payors, health economists, regulators and policy makers attended a virtual meeting. There was consensus among the attendees that there is value to preventing the development and treating the progression of early CKD in people who are at high risk for progression, and that surrogate end points should be used to establish efficacy. Attendees also concluded that cost analyses should be holistic and include aspects beyond direct savings for treatment of kidney failure; and that safety data should be collected outside/beyond the duration of a clinical trial. Successful drug development and implementation of effective therapies will require collaboration across sponsors, patients, patient advocacy organizations, medical community, regulators, and payors.

Cost-Effectiveness Analysis of Venetoclax in Combination with Azacitidine Versus Azacitidine Monotherapy in Patients with Acute Myeloid Leukemia Who are Ineligible for Intensive Chemotherapy: From a US Third Party Payer Perspective

OBJECTIVES

Using individual patient-level data from the phase 3 VIALE-A trial, this study assessed the cost-effectiveness of venetoclax in combination with azacitidine compared with azacitidine monotherapy for patients newly diagnosed with acute myeloid leukemia (AML) who are ineligible for intensive chemotherapy, from a United States (US) third-party payer perspective.

METHODS

A partitioned survival model with a 28-day cycle and three health states (event-free survival (EFS), progressive/relapsed disease, and death) was developed to estimate costs and effectiveness of venetoclax + azacitidine versus azacitidine over a lifetime (25-year) horizon. Efficacy inputs (overall survival (OS), EFS, and complete remission (CR)/CR with incomplete marrow recovery (CRi) rate) were estimated using VIALE-A data. Best-fit parametric models per Akaike Information Criterion were used to extrapolate OS until reaching EFS and extrapolate EFS until Year 5. Within EFS, the time spent in CR/CRi was estimated by applying the CR/CRi rate to the EFS curve. Past Year 5, patients still in EFS were considered cured and to have the same mortality as the US general population. Mean time on treatment (ToT) for both regimens was based on the time observed in VIALE-A. Costs of drug acquisition, drug administration (initial and subsequent treatments), subsequent stem cell transplant procedures, adverse events (AEs), and healthcare resource utilization (HRU) associated with health states were obtained from the literature/public data and inflated to 2021 US dollars. Health state utilities were estimated using EuroQol-5 dimension-5 level data from VIALE-A; AE disutilities were obtained from the literature. Incremental cost-effectiveness ratios (ICERs) per life-year (LY) and quality-adjusted life-year (QALY) gained were estimated. Deterministic sensitivity analyses (DSA), scenario analyses, and probabilistic sensitivity analyses (PSA) were also performed.

RESULTS

Over a lifetime horizon, venetoclax + azacitidine versus azacitidine led to gains of 1.89 LYs (2.99 vs. 1.10, respectively) and 1.45 QALYs (2.30 vs. 0.84, respectively). Patients receiving venetoclax + azacitidine incurred higher total lifetime costs ($250,486 vs. $110,034 (azacitidine)). The ICERs for venetoclax + azacitidine versus azacitidine were estimated at $74,141 per LY and $96,579 per QALY gained. Results from the DSA and scenario analyses supported the base-case findings, with ICERs ranging from $60,718 to $138,554 per QALY gained. The results were most sensitive to varying the parameters for the venetoclax + azacitidine base-case EFS parametric function (Gompertz), followed by alternative approaches for ToT estimation, treatment costs of venetoclax + azacitidine, standard mortality rate value and ToT estimation, alternative sources to inform HRU, different cure modeling assumptions, and the parameters for the venetoclax + azacitidine base-case OS parametric function (log-normal). Results from the PSA showed that, compared with azacitidine, venetoclax + azacitidine was cost-effective in 99.9% of cases at a willingness-to-pay threshold of $150,000 per QALY.

CONCLUSIONS

This analysis suggests that venetoclax + azacitidine offers a cost-effective strategy in the treatment of patients with newly diagnosed AML who are ineligible for intensive chemotherapy from a US third-party payer perspective.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02993523. Date of registration: 15 December 2016.

Machine learning to predict end stage kidney disease in chronic kidney disease

The purpose of this study was to assess the feasibility of machine learning (ML) in predicting the risk of end-stage kidney disease (ESKD) from patients with chronic kidney disease (CKD). Data were obtained from a longitudinal CKD cohort. Predictor variables included patients' baseline characteristics and routine blood test results. The outcome of interest was the presence or absence of ESKD by the end of 5 years. Missing data were imputed using multiple imputation. Five ML algorithms, including logistic regression, naïve Bayes, random forest, decision tree, and K-nearest neighbors were trained and tested using fivefold cross-validation. The performance of each model was compared to that of the Kidney Failure Risk Equation (KFRE). The dataset contained 748 CKD patients recruited between April 2006 and March 2008, with the follow-up time of 6.3 ± 2.3 years. ESKD was observed in 70 patients (9.4%). Three ML models, including the logistic regression, naïve Bayes and random forest, showed equivalent predictability and greater sensitivity compared to the KFRE. The KFRE had the highest accuracy, specificity, and precision. This study showed the feasibility of ML in evaluating the prognosis of CKD based on easily accessible features. Three ML models with adequate performance and sensitivity scores suggest a potential use for patient screenings. Future studies include external validation and improving the models with additional predictor variables.

Physical Exercise in People with Chronic Kidney Disease-Practices and Perception of the Knowledge of Health Professionals and Physical Activity and Sport Science Professionals about Their Prescription

There is evidence on the need to include physical exercise as a treatment for diseases. A large number of professionals are involved in this, but it is not known how physical exercise is prescribed and which professionals are involved. This research has two objectives: (a) to find out the current practices in Spain regarding the prescription of physical exercise in patients with Chronic Kidney Disease (CKD) and (b) to analyse the perception that different health and physical activity professionals have of their knowledge to prescribe of physical exercise in the treatment of CKD. This is an empirical research with an ex post facto retrospective analysis of the information in a descriptive and correlational way. A total of 692 health and sports professionals participated. A questionnaire validated by a committee of experts was administered. Descriptive analyses were carried out and the differences in the study variables were analysed using Chi-square tests and one-factor Analysis of Variance. From the results obtained, we conclude there is a need to develop specific training programmes in the field of physical exercise for health professionals, as well as the establishment of multiprofessional teams for the prescription of physical exercise in CKD treatment, including physical exercise professionals (Cafyde).

Value-Based Care and Kidney Disease: Emergence and Future Opportunities

The United States health care system has increasingly embraced value-based programs that reward improved outcomes and lower costs. Health care value, defined as quality per unit cost, was a major goal of the 2010 Patient Protection and Affordable Care Act amid high and rising US health care expenditures. Many early value-based programs were specifically designed for patients with end-stage renal disease (ESRD) and targeted toward dialysis facilities, including the ESRD Prospective Payment System, ESRD Quality Incentive Program, and ESRD Seamless Care Organizations. While a great deal of attention has been paid to these ESRD-focused programs, other value-based programs targeted toward hospitals and health systems may also affect the quality and costs of care for a broader population of patients with kidney disease. Value-based care for kidney disease is increasingly relevant in light of the Advancing American Kidney Health initiative, which introduces new value-based payment models: the mandatory ESRD Treatment Choices Model in 2021 and voluntary Kidney Care Choices Model in 2022. In this review article, we summarize the emergence and impact of value-based programs on the quality and costs of kidney care, with a focus on federal programs. Key opportunities in value-based kidney care include shifting the focus toward chronic kidney disease, enhancing population health management capabilities, improving quality measurement, and leveraging programs to advance health equity.

Multidisciplinary care program in pre-end-stage kidney disease from 2010 to 2018 in Taiwan

BACKGROUND

The Taiwanese government launched a universal pay-for-performance (P4P) program in 2006 to promote multidisciplinary care for patients with stage 3b-5 chronic kidney disease (CKD). This study aimed to understand the enrollments, care processes, and outcomes of the P4P program between 2010 and 2018.

METHODS

We conducted a population-based study using the Taiwan National Health Insurance Research Data. We divided the incident dialysis population into joining and not joining P4P groups based on whether patients had joined the pre-ESRD program before dialysis or not. Trends in the medications prescribed, anemia correction, vascular access preparation before dialysis initiation, and cumulative survival rate were compared.

RESULTS

The program included more than 100,000 patients with late-stage CKD. Enrollment increased by almost 100% from 2010 to 2018, with increases seen in those over 75 years old (127.5%), male (96.7%), and earlier CKD stages (≥35% stage 3b in 2018). Females were more likely to stay being enrolled. The joining P4P group was prescribed more appropriate medications, such as erythropoietin-stimulating agents and statins. However, a high number of patients were still prescribed metformin (≥40%) and non-steroidal anti-inflammatory drugs (≥20%). Compared to the not joining P4P group, the patients in the P4P group had better anemia management, dialysis preparation, and post-dialysis survival.

CONCLUSION

The patients in the joining P4P program group were delivered more appropriate CKD care and were associated with better survival outcomes. Polices and action plans are needed to extend the coverage of and enrollment in the P4P program.

Projection of the health and economic impacts of Chronic kidney disease in the Chilean population

BACKGROUND

Chronic Kidney Disease (CKD) is a leading public health problem, with substantial burden and economic implications for healthcare systems, mainly due to renal replacement treatment (RRT) for end-stage kidney disease (ESKD). The aim of this study is to develop a multistate predictive model to estimate the future burden of CKD in Chile, given the high and rising RRT rates, population ageing, and prevalence of comorbidities contributing to CKD.

METHODS

A dynamic stock and flow model was developed to simulate CKD progression in the Chilean population aged 40 years and older, up to the year 2041, adopting the perspective of the Chilean public healthcare system. The model included six states replicating progression of CKD, which was assumed in 1-year cycles and was categorised as slow, medium or fast progression, based on the underlying conditions. We simulated two different treatment scenarios. Only direct costs of treatment were included, and a 3% per year discount rate was applied after the first year. We calibrated the model based on international evidence; the exploration of uncertainty (95% credibility intervals) was undertaken with probabilistic sensitivity analysis.

RESULTS

By the year 2041, there is an expected increase in cases of CKD stages 3a to ESKD, ceteris paribus, from 442,265 (95% UI 441,808-442,722) in 2021 to 735,513 (734,455-736,570) individuals. Direct costs of CKD stages 3a to ESKD would rise from 322.4M GBP (321.7-323.1) in 2021 to 1,038.6M GBP (1,035.5-1,041.8) in 2041. A reduction in the progression rates of the disease by the inclusion of SGLT2 inhibitors and pre-dialysis treatment would decrease the number of individuals worsening to stages 5 and ESKD, thus reducing the total costs of CKD by 214.6M GBP in 2041 to 824.0M GBP (822.7-825.3).

CONCLUSIONS

This model can be a useful tool for healthcare planning, with development of preventive or treatment plans to reduce and delay the progression of the disease and thus the anticipated increase in the healthcare costs of CKD.

The role of different nephrology experts in informed shared decision-making for renal replacement therapy

BACKGROUND

Interprofessional teams and peer support are being increasingly considered in informed shared decision-making. In Germany, there appear to be deficits in the implementation of informed shared decision-making in the choice of renal replacement therapy, such as the lack of collaboration in interprofessional teams and the absence of structured peer support programmes for patients with chronic kidney disease.

OBJECTIVE

To explore nephrologists' and nurses' perspectives regarding their involvement in shared decision-making when choosing renal replacement therapy.

DESIGN

Guideline-based, problem-centred interviews were used.

PARTICIPANTS

A total of 20 nephrologists and 15 nurses were recruited from 21 dialysis units all over Germany.

APPROACH

Interviews were audio-recorded and transcribed. They were analysed thematically using structuring and summary content analysis, supported by the qualitative data analysis software MAXQDA 12.

RESULTS

The most important findings were the late or missing participation of nurses in the informed shared decision-making process and the unstructured peer support. Along with time and financial factors, these aspects were seen as barriers to shared decision-making with patients who are often overwhelmed by the diagnosis. Furthermore, informed shared decision-making has been insufficiently considered in professional education and training.

CONCLUSION

Shared decision-making in the choice of renal replacement therapy is particularly challenging due to the patients' high disease burden. The greater incorporation of informed shared decision-making in education and training as well as the consistent involvement of nursing staff and structured peer counselling already in the predialysis phase with adequate reimbursement can address the identified hurdles.

Patient-Reported Experiences with Dialysis Care and Provider Visit Frequency

BACKGROUND AND OBJECTIVES

New payment models resulting from the Advancing American Kidney Health initiative may create incentives for nephrologists to focus less on face-to-face in-center hemodialysis visits. This study aimed to understand whether more frequent nephrology practitioner dialysis visits improved patient experience and could help inform future policy.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In a cross-sectional study of patients receiving dialysis from April 1, 2015 through January 31, 2016, we linked patient records from a national kidney failure registry to patient experience data from the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems survey. We used a multivariable mixed effects linear regression model to examine the association between nephrology practitioner visit frequency and patient-reported experiences with nephrologist care.

RESULTS

Among 5125 US dialysis facilities, 2981 (58%) had ≥30 In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems surveys completed between April 2015 and January 2016, and 243,324 patients receiving care within these facilities had Medicare Parts A/B coverage. Face-to-face practitioner visits per month were 71% with four or more visits, 17% with two to three visits, 4% with one visit, and 8% with no visits. Each 10% absolute greater proportion of patients seen by their nephrology practitioner(s) four or more times per month was associated with a modestly but statistically significant lower score of patient experience with nephrologist care by -0.3 points (95% confidence interval, -0.5 to -0.1) and no effect on experience with other domains of dialysis care.

CONCLUSIONS

In an analysis of patient experiences at the dialysis facility level, frequent nephrology practitioner visits to facilities where patients undergo outpatient hemodialysis were not associated with better patient experiences.

Health Service Costs for a Predialysis Dietetic Clinic: A Retrospective Cost Analysis Study

OBJECTIVES

Effect of dietetic consultation (DC) on clinical outcomes is an under-researched component of predialysis education. Predialysis DC has been associated with a 7.5-month delay in requiring dialysis commencement, having potential cost implications for health services. Limited studies have evaluated the possible impact of predialysis DC on health service costs. This study aimed to investigate the hospital health service costs associated for patients attending a predialysis dietetic clinic.

METHODS

A cost analysis comparing hospital health service costs over 4 years in a cohort of predialysis patients with and without DC. Retrospective study data were used (n = 246) along with outpatient renal clinic visits, hospital admissions records to estimate total hospital service costs. A generalized linear model evaluated associations between total cost and the marginal effects of DC and other variables on total costs.

RESULTS

Mean total cost for patients (outpatient visits, admissions, and dialysis) was AUD$178,913 (95% confidence interval = $158,735-$199,090) or $185/day (95% confidence interval = $12-$161). The DC group total costs/day were lower than the no-DC group with a mean difference of $51/day ($155 vs. $206; P = .03). Patients in the DC group had less admissions compared to the no-DC group (6.32 vs. 8.06; P = .02). The highest marginal costs estimated for the entire cohort were lower estimated glomerular filtration rate at admission ($123,511, P = .001), inpatient admissions ($189,333, P < .001), commencing dialysis ($581,812, P < .001), having diabetes ($94,590, P = .014), and cerebrovascular disease ($177,080, P = .01). DC advice did not influence total costs.

CONCLUSIONS

Patients who received DC had lower total health services costs/day compared to those who did not receive DC. Marginal cost analysis indicates the cost difference to be attributed to less time on dialysis and fewer hospital admissions in this retrospective observational cohort. An assessment of dietetic staffing in predialysis renal services is warranted.

Modelling the Cost-Effectiveness of Implementing a Dietary Intervention in Renal Transplant Recipients

Background: The Dietary Approach to Stop Hypertension (DASH) and potassium supplementation have been shown to reduce the risk of death with a functioning graft (DWFG) and renal graft failure in renal transplant recipients (RTR). Unfortunately, a key problem for patients is the adherence to these diets. The aim of this study is to evaluate the cost-effectiveness and budget impact of higher adherence to either the DASH or potassium supplementation. Methods: A Markov model was used to simulate the life course of 1000 RTR in the Netherlands. A societal perspective with a lifetime time horizon was used. The potential effect of improvement of dietary adherence was modelled in different scenarios. The primary outcomes are the incremental cost-effectiveness ratio (ICER) and the budget impact. Results: In the base case, improved adherence to the DASH diet saved 27,934,786 and gained 1880 quality-adjusted life years (QALYs). Improved adherence to potassium supplementation saved €1,217,803 and gained 2901 QALYs. Both resulted in dominant ICERs. The budget impact over a five-year period for the entire Dutch RTR population was €8,144,693. Conclusion: Improving dietary adherence in RTR is likely to be cost-saving and highly likely to be cost-effective compared to the current standard of care in the Netherlands.

The Cost of Transferring Dialysis Care From the Employer-Based Market to Medicare

This cohort study investigates the frequency and characteristics of patients with end-stage kidney disease receiving dialysis who prematurely transition from their employer-based group health plan to Medicare.

Payer budget impact of an artificial intelligence in vitro diagnostic to modify diabetic kidney disease progression

AIM

To evaluate the U.S. payer budget-impact of KidneyIntelX, an artificial intelligence-enabled in vitro diagnostic to predict kidney function decline in Type 2 Diabetic Kidney Disease (T2DKD) patients, stages 1-3b.

MATERIALS AND METHODS

We developed an Excel-based model according to International Society of Pharmacoeconomics and Outcomes Research (ISPOR) good practices to assess U.S. payer budget impact associated with the use of the KidneyIntelX test to optimize therapy T2DKD patients compared to standard of care (SOC) (without KidneyIntelX). A hypothetical cohort of 100,000 stages 1-3b T2DKD patients was followed for 5 years. Peer-reviewed publications were used to identify model parameter estimates. KidneyIntelX costs incremental to SOC (without KidneyIntelX) included test cost, additional prescription medication use, specialist referrals and PCP office visits. Patients managed with KidneyIntelX experienced a 20% slowed progression rate compared to SOC (without KidneyIntelX) attributed to slowed DKD progression, delayed or prevented dialysis and transplants, and reduced dialysis crashes. Associated costs were compared to SOC (without KidneyIntelX). Sensitivity analyses were conducted by varying the definition of progression and the DKD progression rate associated with KidneyIntelX testing and related interventions.

RESULTS

Projected undiscounted base case 5-year savings for 100,000 patients tested with KidneyIntelX were $1.052 billion, attributed mostly to slowed progression through DKD stages. The breakeven point for the health plan adopting KidneyIntelX is expected to occur prior to year 2 after adoption. Sensitivity analysis based on the assessment of the most conservative definition of progression and a 5% reduction in progression rate attributed to KidneyIntelX, resulted in a projected 5-year savings of $145 million associated with KidneyIntelX.

LIMITATIONS AND CONCLUSIONS

Limitations included reliance on literature-based parameter estimates, including effect size of delayed progression supported by the literature. Incorporating KidneyIntelX in contemporary care of early-stage T2DKD patients is projected to result in substantial savings to payers.

A Patient-Inspired Quality Improvement Initiative for Pituitary Adenoma Care

BACKGROUND

Pituitary adenomas (PAs) are common and often require complex multidisciplinary care with multiple specialists. This may result in a healthcare system that is challenging for patients to navigate. Audits of care at our institution revealed opportunities for improvement to better align care with patients' needs.

METHODS

A quality improvement initiative that incorporated a patient advisory committee of patients who had received treatment for PA at our center and their family members were used to help identify opportunities for improvement. The patient-identified gaps in care included the need to coordinate and minimize appointments and the desire for better communication and education. Based on this information, changes were implemented to the pituitary program, including increasing access to the Multidisciplinary Clinic and developing a standardized and centralized triage process.

RESULTS

A pre- and post-intervention analysis consisting of retrospective chart reviews revealed that these changes had an impact on wait times for first assessment, and a significant shift in the location of this first visit - with a larger proportion of patients being seen in the Multidisciplinary Clinic after an intervention.

CONCLUSIONS

We demonstrate that patient involvement, beyond individual patient-physician interactions, can lead to meaningful and observable changes, and can improve the quality of care for PA.

Treatment Costs for Patients with Chronic Kidney Disease Who Received Multidisciplinary Care in a District Hospital in Thailand

Aim

To estimate direct medical treatment costs in patients with pre-dialysis chronic kidney disease (CKD) in a district hospital and to analyze the factors that affected the treatment costs.

Patients and Methods

Data were retrospectively retrieved from the hospital database in the period from January 2015 to December 2017. Patients who were diagnosed with CKD and had visited ambulatory care services at least two times during the index year (January to December 2015) were included. Patients' data were excluded if they had cancer, had received renal replacement therapy, or had been referred to receive treatment at other hospitals. Treatment costs based on the providers' perspectives in the first and second years after the index year were assessed. Descriptive statistics were used to analyze patients' characteristics, and multiple linear regression was used to analyze the factors in the cost model.

Results

Data of 212 patients with CKD stage G3a, G3b, or G4 who met inclusion and exclusion criteria were included for analysis. Average costs for treatment in year 1 and year 2 were not statistically different. Total cost was 5701.34 Thai Baht (THB) per year. The total cost for patients with CKD stage G4 was two times greater than for patients with CKD stage G3. Costs were increased for longer hospitalization, more frequent ambulatory visits, having diabetes mellitus or dyslipidemia as a comorbidity, and uncontrolled fasting blood glucose (FBG). A cost model with R ²=0.906 was provided. Significant predictors were length of stay, ambulatory visits, diabetes mellitus, dyslipidemia, serum creatinine, FBG, and body mass index.

Conclusion

Total annual treatment costs for the 2 years were not different. A more advanced stage of CKD, having diabetes mellitus or dyslipidemia as comorbidities, and uncontrolled FBG were significantly associated with increased costs for treatment in patients with pre-dialysis CKD.

Four years into MACRA: What has changed?

In 2015, Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA), a policy intended to transition Medicare away from pure fee-for-service care to value-based care. MACRA does this by evaluating the cost and quality of providers, resulting in financial bonuses and penalties in Medicare reimbursement. MACRA offers two tracks for participation, the Merit-based Incentive Payment System and the Advanced Alternative Payment Models. Although the payment rules are different for each of the tracks, common to both is an emphasis on holding providers accountable for high-quality, cost-efficient care. Early data suggest that the End-stage renal disease Seamless Care Organizations, an Advanced Alternative Payment Model, resulted in cost-savings concurrent with improved care quality. Additionally, on July 10th 2019, the President signed an executive order that further attempts to improve kidney disease care by shifting its focus away from in-center hemodialysis toward chronic kidney disease care, home-based dialysis, kidney transplantation, and innovating new therapies for kidney disease. These changes to nephrology reimbursement present a unique opportunity to improve patient outcomes in a cost-effective way. A multidisciplinary effort among policy makers, nephrology providers, and patient advocacy groups is critical to ensure these changes in care delivery safeguard and improve patient health.

Multidisciplinary Chronic Kidney Disease Clinic Practices: A Scoping Review

Background:

Multidisciplinary chronic kidney disease (CKD) clinics improve patient outcomes but their optimal design is unclear.

Objective:

To perform a scoping review to identify and describe current practices (structure, function) associated with multidisciplinary CKD clinics.

Design:

Scoping review.

Setting:

Databases included Medline, EMBASE, Cochrane, and CINAHL.

Patients:

Patients followed in multidisciplinary CKD clinics globally.

Measurements:

Multidisciplinary CKD clinic composition, entry criteria, follow-up, and outcomes.

Methods:

We systematically searched the literature to identify randomized controlled trials, non-randomized interventional studies, or observational studies of multidisciplinary CKD clinics defined by an outpatient setting where two or more allied health members (with or without a nephrologist) provided longitudinal care to 50 or more adult or pediatric patients with CKD. Included studies were from 2002 to present. Searches were completed on August 10, 2018. Title, abstracts, and full texts were screened independently by two reviewers with disagreements resolved by a third. We abstracted data from included studies to summarize multidisciplinary CKD clinic team composition, entry criteria, follow-up, and processes.

Results:

40 studies (8 randomized controlled trials and 32 non-randomized interventional studies or observational studies) involving 23 230 individuals receiving multidisciplinary CKD care in 12 countries were included. Thirty-eight focused on adults (27 with CKD, 10 incident dialysis patients, one conservative therapy) while two studies focused on adolescents or children with CKD. The multidisciplinary team included a mean of 4.6 (SD 1.5) members consisting of a nephrologist, nurse, dietician, social worker, and pharmacist in 97.4%, 86.8%, 84.2%, 57.9%, and 42.1% of studies respectively. Entry criteria to multidisciplinary CKD clinics ranged from glomerular filtration rates of 20 to 70 mL/min/1.73m² or CKD stages 1 to 5 without any proteinuria or risk equation-based criteria. Frequency of follow-up was variable by severity of kidney disease. Team member roles and standardized operating procedures were infrequently reported.

Limitations:

Unstandardized definition of multidisciplinary CKD care, studies limited to CKD defined by glomerular filtration rate, and lack of representation from countries other than Canada, Taiwan, the United States, and the United Kingdom.

Conclusions:

There is heterogeneity in multidisciplinary CKD team composition, entry criteria, follow-up, and processes with inadequate reporting of this complex intervention. Additional research is needed to determine the best model for multidisciplinary CKD clinics.

Trial registration:

Not applicable.

The association between dietetic consultation and time to dialysis for patients attending a pre-dialysis clinic: A retrospective cohort study

AIM

A multidisciplinary approach, including dietetics, is considered the optimal model of care for dialysis preparation. Dietetic consultation (DC) focuses on symptom management and dietary changes to delay time to dialysis. Evidence of the effectiveness of DC on time to dialysis is limited. This study aimed to investigate the impact of DC on time to dialysis for patients attending a pre-dialysis clinic.

METHODS

A retrospective cohort study was designed to include all patients attending outpatient pre-dialysis clinics at a large metropolitan renal service between January 2014 and March 2018. Time to dialysis (days) was compared between patients that received DC and those who did not. Cox proportional hazards analysis allowing for adjustment of differences and confounders was undertaken.

RESULTS

A cohort of 246 patients was identified. Median estimated glomerular filtration rate was 16mL/min per 1.73 m² (interquartile range = 13-20) at initial pre-dialysis clinic visit and 63% commenced dialysis during the study period. Only 41% of patients received dietetic consultation. Significantly fewer patients needed to commence dialysis in the DC group compared to the no-DC group (hazards ratio 0.63; 95% confidence interval (CI) 0.45-0.89; P = 0.008 Cox proportion hazard). The DC group commenced dialysis significantly later than the no-DC group; 933 days (95% CI 832-1034) versus 710 days (95% CI 630-790) respectively, after the initial pre-dialysis clinic visit; log-rank 0.005.

CONCLUSION

DC provided to patients attending a pre-dialysis clinic was associated with a delayed time to dialysis. Standardised referral pathways to improve patient access to renal dietetic services are recommended to optimise care.

Effect of nephrology referrals and multidisciplinary care programs on renal replacement and medical costs on patients with advanced chronic kidney disease: A retrospective cohort study

Evidence-based studies have revealed outcomes in patients with chronic kidney disease that differed depending on the design of care delivery. This study compared the effects of 3 types of nephrology care: multidisciplinary care (MDC), nephrology care, and non-nephrology care. We studied their effects on the risks of requiring dialysis and the differences between these methods had on long-term medical resource utilization and costs.We conducted a retrospective cohort study involving patients with an estimated glomerular filtration rate of (eGFR) ≤45 mL/min/1.73 m from 2005 to 2007. Patients were divided into MDC, non-MDC, and non-nephrology referral groups. Between-group differences with regard to the risk of requiring dialysis and annual medical utilization and costs were evaluated using a 5-year follow-up period.In total, 661 patients were included. After other covariates and the competing risk of death were taken into account, we observed a significant (56%) reduction in the incidence of dialysis in both the MDC and non-MDC groups relative to the non-nephrology referral group. Costs were markedly lower in the MDC group relative to the other groups (average savings: US$ 830 per year; 95% confidence interval: 367-1295; P < .001).For patients without nephrology referrals, MDC can substantially reduce their risk of developing end-stage renal disease and lower their medical costs. We therefore strongly advocate that all patients with an eGFR of ≤45 mL/min/1.73 m should be referred to a nephrologist and receive MDC.

A Primer on Quality Assurance and Performance Improvement for Interprofessional Chronic Kidney Disease Care: A Path to Joint Commission Certification

Interprofessional care for chronic kidney disease facilitates the delivery of high quality, comprehensive care to a complex, at-risk population. Interprofessional care is resource intensive and requires a value proposition. Joint Commission certification is a voluntary process that improves patient outcomes, provides external validity to hospital administration and enhances visibility to patients and referring providers. This is a single-center, retrospective study describing quality assurance and performance improvement in chronic kidney disease, Joint Commission certification and quality outcomes. A total of 440 patients were included in the analysis. Thirteen quality indicators consisting of clinical and process of care indicators were developed and measured for a period of two years from 2009–2017. Significant improvements or at least persistently high performance were noted for key quality indicators such as blood pressure control (85%), estimation of cardiovascular risk (100%), measurement of hemoglobin A1c (98%), vaccination (93%), referrals for vascular access and transplantation (100%), placement of permanent dialysis access (61%), discussion of advanced directives (94%), online patient education (71%) and completion of office visit documentation (100%). High patient satisfaction scores (94–96%) are consistent with excellent quality of care provided.

Patient and provider experience and perspectives of a risk-based approach to multidisciplinary chronic kidney disease care: a mixed methods study

BACKGROUND

The Kidney Failure Risk Equation (KFRE) predicts risk of progression to kidney failure and is used to guide clinical decisions for patients with chronic kidney disease (CKD).

METHODS

The KFRE was implemented to guide access to multidisciplinary care for CKD patients in Alberta, Canada, based on their 2-year risk of kidney failure. We used a mixed methods approach to investigate patients' and providers' perspectives and experiences 1 year following KFRE implementation. We conducted post-implementation interviews with multidisciplinary clinic providers and with low-risk patients who transitioned from multidisciplinary to general nephrology care. We also administered pre- and post-implementation patient care experience surveys, targeting both low-risk patients discharged to general nephrology and high-risk patients who remained in the multidisciplinary clinic, and provider job satisfaction surveys.

RESULTS

Twenty-seven interviews were conducted (9 patients, 1 family member, 17 providers). Five categories were identified among patients and providers: targeted care; access to resources outside the multidisciplinary clinics; self-efficacy; patient reassurance and reduced stress; and transition process for low-risk patients Two additional categories were identified among providers only: anticipated concerns and job satisfaction. Patients and providers reported that the risk-based approach allowed the clinic to target care to those most likely to experience kidney failure and most likely to benefit from multidisciplinary care. While some participants indicated the risk-based model enhanced the sustainability of the clinics, others expressed concern that care for low-risk patients discharged from multidisciplinary care, or those now considered ineligible, may be inadequate. Overall, 413 patients completed the care experience survey and 73 providers completed the workplace satisfaction survey. The majority of patients were satisfied with their care in both periods with no overall differences. When considering the responses "Always" and "Often" together versus not, there were statistically significant improvements in domains of access to care, caring staff, and safety of care. There were no differences in healthcare providers' job satisfaction following KFRE implementation.

CONCLUSIONS

Patients and healthcare providers reported that the risk-based approach improved the focus of the multidisciplinary CKD clinics by targeting patients at highest risk, with survey results suggesting no difference in patient care experience or healthcare provider job satisfaction.

Multidisciplinary clinics reduce treatment costs and improve patient outcomes in diabetic foot disease

OBJECTIVE

Diabetic foot disease poses a significant and rising financial burden on health care systems worldwide. This study investigated the effect of a new multidisciplinary diabetic foot clinic (MDDFC) in a large tertiary hospital on patient outcomes and treatment cost.

METHODS

Patients' records were retrospectively reviewed to identify all patients who had been managed in a new MDDFC between July 2014 and July 2017. The wound episode-the period from initial presentation to the achievement of a final wound outcome-was identified, and all relevant inpatient and outpatient costs were extracted using a fully absorbed activity-based costing methodology. Risk factor, treatment, outcome, and costing data for this cohort were compared with a group of patients with diabetic foot wounds who had been managed in the same hospital before the advent of the MDDFC using a generalized linear mixed model.

RESULTS

The MDDFC and pre-MDDFC cohorts included 73 patients with 80 wound episodes and 225 patients with 265 wound episodes, respectively. Compared with the pre-MDDFC cohort, the MDDFC group had fewer inpatient admissions (1.56 vs 2.64; P ≤ .001). MDDFC patients had a lower major amputation rate (3.8% vs 27.5%; P ≤ .001), a lower mortality rate (7.5% vs 19.2%; P ≤ .05), and a higher rate of minor amputation (53.8% vs 31.7%; P ≤ .01). No statistically significant difference was noted in the rate of excisional débridement, skin graft, and open or endovascular revascularization. In the MDDFC cohort, the median total cost, inpatient cost, and outpatient cost per wound episode was New Zealand dollars (NZD) 22,407.465 (U.S. dollars [USD] 17,253.74), NZD 21,638.93 (USD 16,661.97), and NZD 691.915 (USD 532.77), respectively. The MDDFC to pre-MDDFC wound episode total cost ratio was 0.7586 (P < .001).

CONCLUSIONS

This study is the first to compare the cost and treatment outcomes of diabetic foot patients treated in a large tertiary hospital before and after the introduction of an MDDFC. The results show that an MDDFC improves patient outcomes and reduces the cost of treatment. MDDFCs should be adopted as the standard of care for diabetic foot patients.

Where Are You Going, Nephrology? Considerations on Models of Care in an Evolving Discipline

Nephrology is a complex discipline, including care of kidney disease, dialysis, and transplantation. While in Europe, about 1:10 individuals is affected by chronic kidney disease (CKD), 1:1000 lives thanks to dialysis or transplantation, whose costs are as high as 2% of all the health care budget. Nephrology has important links with surgery, bioethics, cardiovascular and internal medicine, and is, not surprisingly, in a delicate balance between specialization and comprehensiveness, development and consolidation, cost constraints, and competition with internal medicine and other specialties. This paper proposes an interpretation of the different systems of nephrology care summarising the present choices into three not mutually exclusive main models (“scientific”, “pragmatic”, “holistic”, or “comprehensive”), and hypothesizing an “ideal-utopic” prevention-based fourth one. The so-called scientific model is built around kidney transplantation and care of glomerulonephritis and immunologic diseases, which probably pose the most important challenges in our discipline, but do not mirror the most common clinical problems. Conversely, the pragmatic one is built around dialysis (the most expensive and frequent mode of renal replacement therapy) and pre-dialysis treatment, focusing attention on the most common diseases, the holistic, or comprehensive, model comprehends both, and is integrated by several subspecialties, such as interventional nephrology, obstetric nephrology, and the ideal-utopic one is based upon prevention, and early care of common diseases. Each model has strength and weakness, which are commented to enhance discussion on the crucial issue of the philosophy of care behind its practical organization. Increased reflection and research on models of nephrology care is urgently needed if we wish to rise to the challenge of providing earlier and better care for older and more complex kidney patients with acute and chronic kidney diseases, with reduced budgets.

What is the value of multidisciplinary care for chronic kidney disease?

In a Persepctive, Richard Fluck and Maarten Taal discuss the potential value of implementing multidisciplinary care programs for chronic kidney disease.