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

Abstract

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.

Effect of multidisciplinary care on diabetic kidney disease: a retrospective cohort study

“…Covariates used for PS calculation were sex, age, number of hospital beds, index eGFR, duration of diabetes, medications, and procedures. Other covariates were not used because of missing values, and we believe that the covariates used were sufficient to adjust for confounding factors based on previous studies [ 18 , 32 – 34 ]. We used 1:5 matching, a logistic regression model, and the non-replacement nearest-neighbor method with a caliper width of 0.2 of the SD.…”

Mind the gap in kidney care: Translating what we know into what we do

“…Patients are often managed by multiple specialists, leading to fragmentation of care, lack of holistic oversight and diffusion of responsibility for treatment. Multidisciplinary care improved transition to kidney replacement therapy and lowered mortality in single and combined outcomes analyses (Rios et al, 2022). Novel models of ‘combined clinics’ with on‐site collaboration and coparticipation (nephrologist–cardiologist–endocrinologist) may prove to be of substantial benefit for patients, in terms of reduced fragmentation of care, logistics and cost saving.…”

Equity and Quality of Global Chronic Kidney Disease Care: What Are We Waiting for?

“…Policies enable rational utilization of resources, guide funding for infrastructure development, and allocation of services for optimal utilization and maximal benefit of end-users. Indeed, success of a national CKD policy has been observed in Uruguay where, since incorporation of screening for CKD in high-risk populations (case finding) into mandatory health checkups of the working population in 2009 quality of care has improved, with patients being better prepared for KRT (e.g., 44.2% vs. 21.2% having an arteriovenous fistula at the start of dialysis) and mortality among people with CKD has decreased (6.74-4.92 deaths/100 patient years) [65,66]. The ISN-Global Kidney Health Atlas (GKHA) survey found that under half of the 160 participant countries (47%) had a national NCD strategy [67].…”