Early referral strategies for management of people with markers of renal disease: a systematic review of the evidence of clinical effectiveness, cost-effectiveness and economic analysis

Abstract

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Provider and Care Characteristics Associated with Timing of Dialysis Initiation

“…Guidelines for vascular access placement (13) might have created unintended consequences; after the access is ready for use, providers may have lower thresholds for initiating dialysis. Many retrospective cohort studies have suggested a survival benefit during the first 1 year of dialysis for patients who receive predialysis nephrology care and patients who initiate dialysis with an arteriovenous fistula or graft (13)(14)(15)(16)(17)(18)(19)(20)(21)(22). Analyses that evaluate the influence of predialysis nephrology care and dialysis access at initiation on outcomes may suffer from lead time bias; nephrologists may accelerate dialysis start dates for well-prepared patients under their care, and survival analyses that begin with dialysis initiation may show better survival in well-prepared patients.…”

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

“…In addition to clinical underutilization, there is also uncertainty with respect to whether there are additional costs or savings when implementing early intervention programs (11)(12)(13)(14). One study looked at stage 4 CKD patients who were under the care of a nephrologist (12), but this study involved later stage CKD with creatinine clearance of 20 ml/min or lower.…”

“…A different cost-effectiveness analysis that included patients over 50 years of age with proteinuria indicated that early screening was cost-effective for ages 60 and over or cases with hypertension and not diabetes (13). However, neither of these studies included costs for cardiovascular outcomes, and each was based on cohort studies or literature evidence (11). A subsequent cost-effectiveness analysis based on a trial of early screening for albuminuria included patients with normal BP and cholesterol levels (14).…”

Why multidisciplinary clinics should be the standard for treating chronic kidney disease

“…The impressive improvement in the eGFR should convince other government and funding agencies to implement similar approaches, because the data show that dialysis costs could be deferred as a result of slowing the progression of CKD. The substantial savings in dialysis costs from following similar strategies, including early referral, have also been highlighted in studies of adults, although substantial gaps remain in what we know about slowing this disease [22].…”