Augmented Nurse Care Management in CKD Stages 4 to 5: A Randomized Trial

Abstract

The augmented nurse care management intervention resulted in reduced hospitalizations in late-stage CKD and there were suggestions of improved end-stage kidney disease preparation. Given suboptimal outcomes in late-stage CKD, care management interventions could potentially improve patient outcomes.

Opportunities for Increasing the Rate of Preemptive Kidney Transplantation

“…Two recent studies indicate the possibility and feasibility of increasing preemptive transplantation rates. Fishbane et al (3) found that 13% of patients taking part in a care management program underwent preemptive transplants. Similarly, Khosla et al (4), in a description of a comprehensive CKD center, reported a 24% rate.…”

A Cost-Minimization Analysis of Nurse-Led Virtual Case Management in Late-Stage CKD

“…We drew our estimates from the only published data directly in the CKD population. 10 Although additional data in CKD would be ideal to strengthen the evidence, it is important to note that similar estimates have been observed in home-monitoring interventions in heart failure populations. Drawing a parallel between CKD at high risk of kidney failure and heart failure is not unreasonable: both conditions, for example, are singleorgan diseases with systemic consequences, both share a propensity to fluid retention and pulmonary edema, and as a consequence volume management and monitoring is a large component of ongoing care in both.…”

“…22 We assumed that the intervention would afford a relative risk of 0.66 for hospitalization events and a relative risk of 0.5474 for the probability of experiencing a suboptimal dialysis initiation. 10 Univariate sensitivity analysis was performed by varying model inputs AE50% from baseline, or until a theoretical maximum or minimum (e.g., compliance cannot exceed 100%). The annual discount rate was varied between 0% and 5%.…”

“…An overview of model inputs, data sources, ranges for sensitivity analysis, and assumed distributions is provided in Table 1. 4,9,10,14,22 Internal model validity was evaluated by comparing output from the microsimulation to inputs used in the model. In the status quo comparator scenario, 72,656 patients in a hypothetical cohort of 100,000 are expected to initiate dialysis.…”

“…8 Unfortunately, even among patients followed by a nephrologist and multidisciplinary care team, 50% or more experience a suboptimal initiation of dialysis. 9,10 Moreover, more than half of dialysis initiations involve a hospitalization or emergency department visit due to severe uremic symptoms, volume overload, or hyperkalemia. 7 Initiating dialysis earlier at a higher kidney function before patients are symptomatic and when there is less risk of suboptimal starts is not an ideal solution, as it increases health care costs without a clinical benefit.…”