Clinical Outcomes of a Novel Multidisciplinary Care Program in Advanced Kidney Disease (PEAK)

IF 8.3 2区材料科学 Q1 MATERIALS SCIENCE, MULTIDISCIPLINARY

ACS Applied Materials & Interfaces Pub Date : 2024-10-01 DOI:10.1016/j.ekir.2024.07.018

Daniil Shimonov , Sri Lekha Tummalapalli , Stephanie Donahue , Vidya Narayana , Sylvia Wu , Lisa S. Walters , Roberta Billman , Barbara Desiderio , Sandra Pressman , Oliver Fielding , Kariel Sweeney , Daniel Cukor , Daniel M. Levine , Thomas S. Parker , Vesh Srivatana , Jeffrey Silberzweig , Frank Liu , Andrew Bohmart

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Abstract

Introduction

Multidisciplinary care (MDC) for late-stage chronic kidney disease (CKD) has been associated with improved patient outcomes compared with traditional nephrology care; however, the optimal MDC model is unknown. In 2015, we implemented a novel MDC model for patients with late-stage CKD informed by the Chronic Care Model conceptual framework, including an expanded MDC team, care plan meetings, clinical risk prediction, and a patient dashboard.

Methods

We conducted a single-center, retrospective cohort study of adults with late-stage CKD (estimated glomerular filtration rate [eGFR] < 30 ml/min per 1.73 m²) enrolled from May 2015 to February 2020 in the Program for Education in Advanced Kidney Disease (PEAK). Our primary composite outcome was an optimal transition to end-stage kidney disease (ESKD) defined as starting in-center hemodialysis (ICHD) as an outpatient with an arteriovenous fistula (AVF) or graft (AVG), or receiving home dialysis, or a preemptive kidney transplant. Secondary outcomes included home dialysis initiation, preemptive transplantation, vascular access at dialysis initiation, and location of ICHD initiation. We used logistic regression to examine trends in outcomes. Results were stratified by race, ethnicity, and insurance payor, and compared with national and regional averages from the United States Renal Data System (USRDS) averaged from 2015 to 2019.

Results

Among 489 patients in the PEAK program, 37 (8%) died prior to ESKD and 151 (31%) never progressed to ESKD. Of the 301 patients (62%) who progressed to ESKD, 175 (58%) achieved an optimal transition to ESKD, including 54 (18%) on peritoneal dialysis, 16 (5%) on home hemodialysis, and 36 (12%) to preemptive transplant. Of the 195 patients (65%) starting ICHD, 51% started with an AVF or AVG and 52% started as an outpatient. The likelihood of starting home dialysis increased by 1.34 times per year from 2015 to 2020 (95% confidence interval [CI]: 1.05–1.71, P = 0.018) in multivariable adjusted results. Optimal transitions to ESKD and home dialysis rates were higher than the national USRDS data (58% vs. 30%; 23% vs. 11%) across patient race, ethnicity, and payor.

Conclusion

Patients enrolled in a novel comprehensive MDC model coupled with risk prediction and health information technology were nearly twice as likely to achieve an optimal transition to ESKD and start dialysis at home, compared with national averages.

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晚期肾病新型多学科护理计划（PEAK）的临床效果

导言与传统肾脏病护理相比，晚期慢性肾脏病（CKD）的多学科护理（MDC）可改善患者的预后；然而，最佳的 MDC 模式尚不清楚。2015 年，我们根据慢性病护理模式概念框架，为晚期 CKD 患者实施了一种新型 MDC 模式，包括扩大的 MDC 团队、护理计划会议、临床风险预测和患者仪表板。方法我们对 2015 年 5 月至 2020 年 2 月参加晚期肾病教育项目（PEAK）的晚期 CKD 成人患者（估计肾小球滤过率 [eGFR] < 30 ml/min 每 1.73 m2）进行了单中心回顾性队列研究。我们的主要综合结果是向终末期肾病（ESKD）的最佳过渡，即作为门诊病人开始中心内血液透析（ICHD），并伴有动静脉瘘（AVF）或移植物（AVG），或接受家庭透析，或进行先期肾移植。次要结果包括开始家庭透析、抢先移植、开始透析时的血管通路以及开始 ICHD 的地点。我们采用逻辑回归法检测结果的变化趋势。结果按种族、民族和保险支付方进行了分层，并与美国肾脏数据系统（USRDS）2015 年至 2019 年的全国和地区平均值进行了比较。结果在 PEAK 项目的 489 名患者中，37 人（8%）在 ESKD 之前死亡，151 人（31%）从未进展为 ESKD。在进展为 ESKD 的 301 名患者（62%）中，175 名（58%）实现了向 ESKD 的最佳过渡，其中 54 名（18%）接受腹膜透析，16 名（5%）接受家庭血液透析，36 名（12%）接受先期移植。在 195 名（65%）开始接受 ICHD 的患者中，51% 开始接受 AVF 或 AVG，52% 开始接受门诊治疗。多变量调整结果显示，从 2015 年到 2020 年，开始家庭透析的可能性每年增加 1.34 倍（95% 置信区间 [CI]：1.05-1.71，P = 0.018）。结论与全国平均水平相比，加入新型综合 MDC 模型并结合风险预测和健康信息技术的患者实现最佳 ESKD 过渡和开始家庭透析的几率几乎是全国平均水平的两倍。

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来源期刊

ACS Applied Materials & Interfaces 工程技术-材料科学：综合

CiteScore

16.00

自引率

6.30%

发文量

4978

审稿时长

1.8 months

期刊介绍： ACS Applied Materials & Interfaces is a leading interdisciplinary journal that brings together chemists, engineers, physicists, and biologists to explore the development and utilization of newly-discovered materials and interfacial processes for specific applications. Our journal has experienced remarkable growth since its establishment in 2009, both in terms of the number of articles published and the impact of the research showcased. We are proud to foster a truly global community, with the majority of published articles originating from outside the United States, reflecting the rapid growth of applied research worldwide.