title: The short- and long-term impact of multi-disciplinary clinics in addition to standard nephrology care on patient outcomes.
abstract: BACKGROUND
  This two country case control study of incident dialysis patients evaluates the outcomes of patients exposed to formalized multi-disciplinary clinic (MDC) programmes vs standard nephrologist care.
  
  
  METHODS
  Patients commencing dialysis in two centres (Vancouver, Canada and Cremona, Italy) were evaluated at and after dialysis start, as a function of MDC exposure vs nephrologist care alone. Only chronic kidney disease patients, with longer than 3 months of exposure to nephrology care, who had not previously received kidney replacement therapy were included. Study outcomes included laboratory parameters and survival. The MDC was similar in both countries and average exposure was 6-8 h per patient-year, as compared to 2-4 h for standard care. All patients had equal access to resources prior to dialysis and with respect to dialysis start, as all had been referred to the same local nephrology practices.
  
  
  RESULTS
  During the evaluation period 288 patients commenced dialysis after receiving more than 3 months nephrology care prior to dialysis. There were no major demographic differences between the cohorts. Mean duration of nephrology care prior to dialysis was 42 months, and dialysis was initiated at similar low glomerular filtration rate (GFR), though statistically significantly different (7.0 and 8.4 ml/min/m2, P = 0.001). The MDC patients had higher haemoglobin (102 vs 90 g/l, P<0.0001), albumin (37.0 vs 34.8 g/l, P = 0.002) and calcium levels (2.29 vs 2.16 mmol/l, P<0.0001) at dialysis start. Survival was significantly better in the MDC group demonstrated by Kaplan-Meier analysis (P = 0.01). Cox proportional hazards analysis demonstrated standard nephrology clinic vs MDC attendance was a statistically significant independent predictor of death (hazards ratio = 2.17, 95% confidence interval 1.11-4.28) after adjusting for other variables known to impact outcomes.
  
  
  CONCLUSIONS
  This analysis of outcomes in two different countries suggests that despite equal and long exposure to nephrology care prior to dialysis, there appears to be an association of survival advantage for those patients exposed to formalized clinic care in addition to standard nephrologist follow-up. While other known predictors of survival such as adequacy of dialysis and severity of illness measures were not included in the model, those parameters require time on dialysis to be accumulated. Thus, the data do suggest that knowledge of patient status at the time of dialysis start is important. Further research is needed to determine which specific components of care both prior to dialysis and after its commencement are most important with respect to outcomes.
authors.affiliation: Division of Nephrology, Patient Research Center, Memorial University of Newfoundland, Canada.
authors.forename: Bryan M
authors.initials: BM
authors.lastname: Curtis
authors.forename: Pietro
authors.initials: P
authors.lastname: Ravani
authors.forename: F
authors.initials: F
authors.lastname: Malberti
authors.forename: Fiona
authors.initials: F
authors.lastname: Kennett
authors.forename: Paul A
authors.initials: PA
authors.lastname: Taylor
authors.forename: Ognjenka
authors.initials: O
authors.lastname: Djurdjev
authors.forename: Adeera
authors.initials: A
authors.lastname: Levin
mesh_terms: D000328:Adult; D000368:Aged; D001955:British Columbia; D016022:Case-Control Studies; D003131:Combined Modality Therapy; D005260:Female; D005500:Follow-Up Studies; D006436:Hemodialysis Units, Hospital / Q000592:standards / Q000706:statistics & numerical data*; D006801:Humans; D007558:Italy; D007676:Kidney Failure, Chronic / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D007677:Kidney Function Tests; D008297:Male; D008875:Middle Aged; D009398:Nephrology / Q000379:methods*; D017063:Outcome Assessment, Health Care; D010348:Patient Care Team; D016016:Proportional Hazards Models; D012017:Referral and Consultation; D006435:Renal Dialysis / Q000592:standards / Q000706:statistics & numerical data*; D016019:Survival Analysis; D013997:Time Factors