Background
Defining the need for interventions in the chronic kidney disease population
Review
Definition and domains of interdisciplinary care clinics
Nephrologist | Evaluates etiology of CKD and determines the care plan |
Advanced practitioner | Educates about CKD and kidney failure treatment options |
Coordinates care with family and members of the IDC team | |
Dietitian | Dietary counseling and fluid management |
Pharmacist | Reviews medications, dosing, and adherence |
Educates patients about the use of over the counter medications and herbal preparations | |
Geriatrician/palliative care | Addresses geriatric and palliative care needs |
Discusses prognosis and ensures treatment plans align with goal of care | |
Case management/social work | Assists patients to obtain needed resources (e.g., transportation and issues with housing) |
Transplant team | Educates patients about transplant options |
Evaluates potential transplant candidates with progressive CKD | |
Vascular surgery/general surgery | Places and monitors access for dialysis (hemodialysis and peritoneal dialysis) |
Interventional radiology | Intervenes on immature or nonfunctioning AVG/AVF to improve access flow in order to initiate dialysis |
Goals of interdisciplinary care clinics
IDC in improving morbidity and mortality
IDC in slowing CKD progression
IDC in transitioning patients from CKD to ESRD
Models of IDCs and barriers to interdisciplinary care
Economics of interdisciplinary care clinics
Target population for interdisciplinary care clinics
Clinical outcomes of interdisclipinary clinics in chronic kidney disease care
Study, year | Study population and design | Exposure or intervention | Outcomes | Major findings | Cost-benefit |
---|---|---|---|---|---|
Curtis et al., 2003 [63] | Retrospective cohort study of 288 incident dialysis patients (mean age 62 years) in Canada and Italy | Formalized multidisciplinary clinic programs consisting of a nurse educator, physician, social worker, nutritionist, and pharmacist | Mortality up to 2.5 years after dialysis initiation | HR 0.46 (95 % CI 0.23–0.90) for IDC group after adjustments for age, sex, calculated GFR at dialysis start, race, diabetes, etiology of kidney failure, and country of treatment | Not assessed |
Goldstein et al., 2004 [12] | Retrospective cohort study of 184 Canadian incident dialysis patients (mean age 60 years) | Progressive multidisciplinary renal disease clinic that included a dietitian, nurse educator, pharmacist, social worker and volunteer peer supporters | Mortality and hospitalizations at 1 year after starting dialysis | Fewer deaths in the IDC group (2 % versus 23 %; P < 0.01) and fewer hospitalizations (7 versus 69.7 days/patient/year (P < 0.01) | Not assessed |
Independent predictors of death were older age, history of cardiovascular disease and non-IDC. | |||||
Hemmelgarn et al., 2009 [61] | Propensity score matched cohort study of 6978 elderly Canadian patients (mean age 76 years) with CKD stage 4 and 5 | Multidisciplinary care clinic utilizing nurses, dietitians and social workers | 1. Mortality 2. All-cause and cardiovascular-specific hospitalizations | HR 0.50 (95 % CI 0.35–0.71) for the IDC group after adjustments for age, gender, baseline GFR, diabetes, and comorbidity score in the MDC group compared to standard group No difference in all-cause (HR 0.83; 95 % CI 0.64– 1.06) or cardiovascular-specific hospitalization (HR 0.76; 95 % CI 0.54 to 1.06) adjusted for age, gender, baseline GFR, diabetes, and comorbidity score | Not assessed |
Wu et al., 2009 [62] | Prospective cohort study of 573 Taiwanese patients (mean age 63 years) with GFR <60 ml/min/1.73 m2 | Multidisciplinary care with nurses for case management, dietitians, volunteer peer supporters | 1. Progression to ESRD | HR 0.117 (95 % CI 0.075–0.183) for the IDC group after adjustments for age, gender, DM and HTN status, baseline eGFR, hemoglobin and albumin | Not assessed |
2. All-cause mortality | HR 0.10 (95 % CI 0.04–0.265) for the IDC group after adjustments for gender, DM and HTN status, baseline eGFR, hemoglobin and albumin | ||||
Wei et al., 2010 [71] | Cohort study of 137 Taiwanese patients (mean age 57 control group and 63 exposed group) with CKD stage 3–5 | Multidisciplinary team including renal nurses and dieticians | Hospitalization for hemodialysis initiation | 40.8 % in the intervention group were not hospitalized compared to 18.8 % in the usual care group (P < 0.005) | Favored intervention |
Lacson et al., 2010 [64] | Matched (1:1) study of 2,800 incident dialysis (mean age 63 years) in the United States | Educational program on treatment options for dialysis | Mortality within the first 90 days of starting dialysis | HR 0.61 (95 % CI 0.50–0.74) for treatment options attendees compared to usual care after adjustments for case-mix and laboratory data | Not assessed |
Barrett et al., 2011 [69] CanPREVENT | Randomized control trial of 474 patients (mean age 67 years) with CKD stage 3 and 4 in Canada | Nurse-coordinated care focused on risk factor modification | Rate of decline in GFR | Nurse-coordinated team did not alter rate of GFR decline | Not assessed |
Baylis et al., 2011 [68] | Cohort study of 2002 patients (mean age 68 years) with CKD stage 3 in the United States | Multidisciplinary team consisting of nephrologist, renal clinical pharmacy specialist, diabetes nurse educator, renal dietitian, social worker, and nephrology nurse | Rate of decline in GFR | Mean annual decline in GFR 1.73 ml/min/1.73 m2 in the intervention group compared to 2.1 ml/min/1.73 m2 in the usual care group after adjustments for nephrology site, follow-up time, race, age, baseline GFR, gender, number of chronic conditions, body mass index, number of GFR measurements, and number of primary care visit (P < 0.0001) | Not assessed |
Devins et al., 2011 [48] | Multi-center randomized control trial of 323 Canadian patients (mean age 54 years) with progressive CKD (deemed likely start dialysis in next 6 to 12 months) | Predialysis psychoeducation | Time to dialysis initiation | Median time to dialysis was 17.0 months in the intervention group compared to 14. 2 months in usual-care control group (P < 0.001) | Not assessed |
Van Zullen et al., 2012 [66] MASTERPLAN | Randomized control trial of 788 patients (mean age 59 years) from the Netherlands with CKD stage 3 and 4 | Addition of nurse practitioner coordinated care | 1. Composite of myocardial infarction, stroke, or cardiovascular death. | No difference (HR 0.90; 95 % CI 0.58–1.39) | |
2. Composite vascular interventions, all-cause mortality or end-stage renal disease | No difference (HR 0.83; 95 % CI 0.57–1.20) | ||||
Peeters et al., 2014 [65] MASTERPLAN | 1. Composite of incident ESRD, death, or 50 % increase in creatinine | HR 0.80 (95 % CI 0.66–0.98) in the intervention group vs. control | Crude estimate of savings and costs favored intervention | ||
2. Difference in slope of GFR | Decrease in estimated GFR was 0.45 ml/min per 1.73 m2 per year less in intervention group vs. control (P = 0.01) |