Abstract
Background and Aims: Multidisciplinary clinics (MDC’s) were established in Canada to offer a variety of support systems (diabetes care, social support, easy access to pharmacists, dietitians, specialty trained nurses), to monitor and delay progression through timed lab investigations and visits in conjunction with the Nephrologist. The reasons for better outcomes have been identified as better education, focus on self-care, dietary interventions, timely transplant referrals, modality education, lower hospitalizations and mortality. Treating all patients with chronic kidney disease (CKD) as part of a multidisciplinary care team runs the risk of adding unwarranted labs, interventions, polypharmacy and costs. Kidney Failure Risk Equation (KFRE) uses routine laboratory and clinical data, to stratify patients into three risk categories (low, medium, and high risk) of progression. KFRE has been shown to accurately estimate progression to kidney failure in adults with CKD. The objectives of the study were to i) validate the KFRE in our CKD patients, ii) evaluate health care utilization of patients based on the risk of progression in our province, Saskatchewan. iii) identify the subgroup of patients that benefit most from follow up in MDC.
Methods: We conducted a retrospective study on 1007 patients with CKD stages G3 and G4 in two CKD multidisciplinary clinics in the province of Saskatchewan, Canada (January 2004-December 2012). The predicted risk of kidney failure (low, medium high) for each patient was calculated using the 8-variable KFRE. Patients were followed for five years to validate the KFRE; data on initiation of dialysis or death was collected. Cost of delivery of care per patient per year in the CKD clinic was determined. Health care utilization was evaluated by measuring the number/cost of hospital admissions, cardiovascular and thoracic (CVT) surgery, non-nephrology specialist appointments, and medications.
Results: There were more patients in G 3 (n= 533) than in G 4 (n=474). 313 (59%), 150 (28%), and 70 (13%) were in low, medium and high-risk categories for G 3 CKD. 275 (58%), 86 (18%), and 113 (24%) were in similar categories for G 4. The mean age (SD) was 71 (12.8) years. The number of patients > 65 years of age was 75%. 57% were men, mean GFR (mls/min/1.73m2) for G3 was 40 (7.8) and 23 (4) for G4. Of the G3 patients, 4% of low risk, 11% of the medium risk and 26% of the high risk progressed to dialysis by 5 years. In G 4 patients, 7% of low risk, 17% of medium risk and 48% of high risk progressed to dialysis over 2 years. These results validate the KFRE in our population. The cost of care per patient in MDC was $ 3800 (CAD) per year. There was a difference in the cost of medications, number and cost of (inpatient hospitalizations, cardiovascular surgeries, non-Nephrology specialist visits, and day surgeries) between low risk patients vs high risk patients in G4 patients.
Conclusion: We performed a cost-effectiveness analysis of our MDC’s and show that very few patients at low-risk of progression advance to ESRD. They are also unlikely to benefit from intensive care management and better managed in primary care with advice from tertiary centres. Individual programs have significant opportunity to improve health care delivery by identifying the sub- groups that benefit the most from MDC based on the risk of progression to allow optimal utilization of resources. At $ 3800 (CAD) per patient, we suggest that MDC’s are best utilized by patients with medium and high risk of progression. Further, we show that patients that the low-risk patients were older, had fewer inpatient visits, had lesser drug costs, underwent fewer cardiovascular surgeries, had fewer day surgery visits, and fewer non-nephrology specialist visits. This is the first study to our knowledge that focuses on health care utilization based on the risk of disease progression rather than the stage of CKD.
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