A Nurse-coordinated Model of Care versus Usual Care for Stage 3/4 Chronic Kidney Disease in the Community

Abstract

SummaryBackground and objectives It is unclear how to optimally care for chronic kidney disease (CKD). This study compares a new coordinated model to usual care for CKD.Design, setting, participants, & measurements A randomized trial in nephrology clinics and the community included 474 patients with median estimated GFR (eGFR) 42 ml/min per 1.73 m 2 identified by laboratorybased case finding compared care coordinated by a general practitioner (controls) with care by a nursecoordinated team including a nephrologist (intervention) for a median (interquartile range [IQR]) of 742 days. 32% were diabetic, 60% had cardiovascular disease, and proteinuria was minimal. Guided by protocols, the intervention team targeted risk factors for adverse kidney and cardiovascular outcomes. Serial eGFR and clinical events were tracked. ResultsThe average decline in eGFR over 20 months was Ϫ1.9 ml/min per 1.73 m 2 . eGFR declined by Ն4 ml/min per 1.73 m 2 within 20 months in 28 (17%) intervention patients versus 23 (13.9%) control patients. Control of BP, LDL, and diabetes were comparable across groups. In the intervention group there was a trend to greater use of renin-angiotensin blockers and more use of statins in those with initial LDL Ͼ2.5 mmol/L. Treatment was rarely required for anemia, acidosis, or disordered mineral metabolism. Clinical events occurred in 5.2% per year.Conclusions Patients with stage 3/4 CKD identified through community laboratories largely had nonprogressive kidney disease but had cardiovascular risk. Over a median of 24 months, the nurse-coordinated team did not affect rate of GFR decline or control of most risk factors compared with usual care.

Cost-Effectiveness Analysis of a Randomized Trial Comparing Care Models for Chronic Kidney Disease

“…Participants were largely Caucasian seniors, living independently, and a little over half were women (18). Baseline estimated GFR (eGFR) by MDRD equation (age, sex, and serum creatinine) centered around 42 ml/min per 1.73 m 2 .…”

“…The methods for the trial and the clinical efficacy have been reported elsewhere (18). In an effort to minimize referral biases, a laboratory-based case finding method was employed as described (18).…”

“…The methods for the trial and the clinical efficacy have been reported elsewhere (18). In an effort to minimize referral biases, a laboratory-based case finding method was employed as described (18). Patients were recruited from 5 centers in Canada (located in Vancouver, BC; London, ON; Greenfield Park, QU; Halifax, NS; and St. John's, NF, and Labrador).…”

“…To extend these findings and determine if similar management of chronic kidney disease is feasible, effective and costeffective, a multicenter randomized control trial was conducted to compare the benefit of a chronic care model compared with usual care (18).…”

Effect of shared care on blood pressure in patients with chronic kidney disease: a cluster randomised controlled trial

“…35 However, in a randomised trial in which patients were randomly assigned to a nurse-coordinated team in secondary care, or to usual care in general practice, no effect on cardiovascular risk-factor control or on clinical end points was found. 36 The opportunity to ask advice from a nephrologist has been studied in a shared care system in the UK. 17 Patients were treated in primary care that was sustained by continuous feedback from nephrologists on the laboratory and blood pressure results.…”