Nephrol Dial Transplant (2013) 28: 671–682 doi: 10.1093/ndt/gfs469 Advance Access publication 6 December 2012
Effectiveness of multidisciplinary care for chronic kidney disease in Taiwan: a 3-year prospective cohort study 1
Division of Nephrology, Changhua Christian Hospital Yun Lin
Yue-Ren Chen1,
Branch, Changhua, Taiwan,
Yu Yang2,3,
2
Division of Nephrology, Internal Medicine, Changhua Christian
2,4
Shu-Chuan Wang ,
Hospital, 135 Nanhsiao Street, Changhua City 500, Taiwan, ROC, 3
School of Medicine, Chung Shan Medical University, Taichung,
Ping-Fang Chiu2,
Taiwan,
Wen-Yu Chou2,
4
School of Public Health, National Defense Medical Center, Taipei,
5
Ching-Yuang Lin ,
Taiwan, 5
College of Medicine, China Medical University, Taichung, Taiwan,
Jer-Ming Chang6,
6
Division of Nephrology, Internal Medicine, Kaohsiung Municipal
Tzen-Wen Chen7,
7
Division of Nephrology, Internal Medicine, Taipei Medical
University Hospital, Taipei, Taiwan,
and Chun-Liang Lin9
8
Division of Nephrology, Internal Medicine, Cathay General
Hospital, Taipei, Taiwan and 9
Division of Nephrology, Internal Medicine, Chiayi Chang Gung
Memorial Hospital, Chiayi, Taiwan
Keywords: chronic kidney disease, hospitalization, multidisciplinary care, mortality, renal replacement therapy
Correspondence and offprint requests to: Yu Yang; E-mail:
[email protected]
function decline, lipid profile, hematocrit and mineral bone disease control. Results. Participants were prone to be male (64.8%) with a mean age of 65.1 years and 33.1 months of mean followup. The MDC group had higher prescription rates of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB), phosphate binder, vitamin D3, uric acid lower agents and erythropoietin-stimulating therapy and better control in secondary hyperparathyroidism. The decline of renal function in advanced stage CKD IV and V was also slower in the MDC group (−5.1 versus −7.3 mL/ min, P = 0.01). The use of temporary dialysis catheter was higher in the usual care group, and CKD patients under MDC intervention exhibited a greater willingness to choose peritoneal dialysis modality. A Cox regression revealed that the MDC group was associated with a 40% reduction in the risk of hospitalization due to infection, and a 51% reduction in patient mortality, but a 68% increase in the risk of initiation dialysis when compared with the usual care group.
A B S T R AC T Background. Previous studies have demonstrated that multidisciplinary pre-dialysis education and team care may slow the decline in renal function for chronic kidney disease (CKD). Our study compared clinical outcomes of CKD patients between multidisciplinary care (MDC) and usual care in Taiwan. Methods. In this 3-year prospective cohort study from 2008 to 2010, we recruited 1056 CKD subjects, aged 20–80 years, from five hospitals, who received either MDC or usual care, had an estimated glomerular filtration rate (eGFR) 16 million adults with stage 3 or higher stage CKD [1]. Approximately 500 000 people were treated by means of renal replacement therapy (RRT) (dialysis or transplantation) for end-stage renal disease (ESRD) in the USA in 2007, and the number of ESRD patients is projected to increase to 700 000 by 2015 and potentially to more than two million by 2030 [2]. In Taiwan, the national prevalence of CKD is high, but awareness of CKD is inadequate. Only 3.5% of patients are able to report their stage of the disease [3]. Notably, subjects with a low socio-economic and educational status have a low awareness of CKD and have a high CKD prevalence [4]. As one of the rapidly aging countries with an increasing prevalence of diabetes, hypertension and subsequently CKDs, Taiwan has the highest prevalence and incidence of ESRD in the world [5]. According to the Bureau of National Health Insurance (BNHI) annual report in 2007, ESRD patients in Taiwan accounted for 0.23% of the local population, but cost 7.2% of the health-care resources. The unbalanced allocation of resources not only creates a financial burden, but may also endanger the welfare of other insured population. Comorbidity such as cardiovascular disease is the major cause of mortality among CKD patients [6–10]. Optimal management of CKD and comorbidity may improve clinical outcome and decrease mortality. In 2002, the US National Kidney Foundation launched the promotion of clinical practice guidelines for the diagnosis, evaluation and monitoring of CKD within the Kidney Disease Outcomes Quality Initiative (NKF K/DOQI) in an effort to increase the awareness of optimal CKD care [11]. It recommends co-management with a nephrologist at stage 3 CKD [estimated glomerular filtration rate (eGFR) 30–59 mL/min/1.73 m2] and a referral no later than stage 4 of CKD (eGFR
