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All authors declare that they have no competing interests.
BL conceived of and implemented the model of care and revised the manuscript for important intellectual content. MT, DM, and YZ conducted data collection, analysis, and interpretation and were involved in drafting and revising the manuscript. TG and LR were instrumental in the conception and design of the evaluation and contributed important concepts to the manuscript. AL was involved in the conception and implementation of the model of care oversight and reviewed the manuscript for important intellectual content. All authors read and approved the final manuscript.
Benefits of early nephrology care are well-established, but as many as 40% of U.S. patients with end-stage renal disease (ESRD) do not see a nephrologist before its onset. Our objective was to evaluate the effect of proactive, population-based nephrologist oversight (PPNO) on chronic kidney disease (CKD) progression.
Retrospective control analysis of Kaiser Permanente Hawaii members with CKD using propensity score matching methods. We matched 2,938 control and case pairs of individuals with stage 3a CKD for the pre-PPNO period (2001–2004) and post-PPNO period (2005–2008) that were similar in other characteristics: age, gender, and the presence of diabetes and hypertension. After three years, we classified the stage outcomes for all individuals. We assessed the PPNO effect across all stages of progression with a χ 2- test. We used the z-score test to assess the proportional differences in progression within a stage.
The progression within the post-PPNO period was less severe and significantly different from the pre-PPNO period (p = 0.027). Within the stages, there were 2.6% more individuals remaining in 3a in the post-period (95% confidence interval [CI], 1.5% to 3.8%; P value < 0.00001). Progression from 3a to 3b was 2.2% less in the post-period (95% [CI], 0.7% to 3.6%; P value = 0.0017), 3a to 4/5 was 0.2% less (95% CI, 0.0% to 0.87%; P value = 0.26), and 3a to ESRD was 0.24% less (95% CI, 0.0% to 0.66%, P value = 0.10).
Proactive, population-based nephrologist oversight was associated with a statistically significant decrease in progression. With enabling health information technology, risk stratification and targeted intervention by collaborative primary and specialty care achieves population-level care improvements. This model may be applicable to other chronic conditions.