title: Towards rational approaches of health care utilization in complex patients: an exploratory randomized trial comparing a novel combined clinic to multiple specialty clinics in patients with renal disease-cardiovascular disease-diabetes.
abstract: BACKGROUND
  Optimal utilization of health care resources for patients with chronic conditions is an increasing focus of health care policy researchers and clinicians. Kidney disease, diabetes (DM) and cardiovascular disease (CVD) often coexist within one individual, but current systems are designed to manage individual conditions. We sought to examine if streamlining medical care of complex patients (two or more conditions) is associated with similar, worse or improved outcomes using a randomized controlled study design.
  
  
  METHODS
  Patients attending a kidney care clinic (KCC) and at least one other specialty clinic of interest (DM, CVD) were randomly assigned to either the 'combined clinic (CC)' arm, where resources from all three were integrated into one clinic, or to the 'standard care' arm with continued attendance at multiple specialty clinics (MC), including the KCC. The primary outcome was hospitalization rate and sample size was calculated based on non-inferiority.
  
  
  RESULTS
  Of 150 subjects enrolled, 11 subjects exited before study commencement: 139 remained for final analysis. Other than older age in the MC group (P = 0.009), the demographics were comparable. Hospitalization rates were not different (95% CI for the difference: 0.013-0.207; P = 0.03). Similar proportions in each group achieved clinical and laboratory targets. Mortality (13%) and dialysis (32%) rates were the same between groups. Differences in the cost of clinic visits alone were $86,400 per year in favor of the CC.
  
  
  CONCLUSIONS
  Medical care of complex patients may be delivered in a single combined specialty clinic as compared to multiple disease specific clinics without compromising patient care or important health outcomes, with demonstrable outpatient costs savings.
authors: Department of Medicine, Division of Nephrology, St Paul's Hospital, University of British Columbia, Vancouver, Canada.
authors: Catherine
authors: C
authors: Weber
authors: Monica
authors: M
authors: Beaulieu
authors: Ognjenka
authors: O
authors: Djurdjev
authors: Lee
authors: L
authors: Er
authors: Paul
authors: P
authors: Taylor
authors: Andrew
authors: A
authors: Ignaszewski
authors: Shelley
authors: S
authors: Burnett
authors: Adeera
authors: A
authors: Levin
mesh_terms: D000368:Aged; D002318:Cardiovascular Diseases / Q000150:complications / Q000191:economics* / Q000401:mortality; D017046:Cost Savings; D003695:Delivery of Health Care / Q000706:statistics & numerical data*; D003924:Diabetes Mellitus, Type 2 / Q000191:economics* / Q000401:mortality / Q000503:physiopathology; D005260:Female; D005500:Follow-Up Studies; D006301:Health Services Needs and Demand / Q000191:economics*; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D007674:Kidney Diseases / Q000191:economics* / Q000209:etiology / Q000401:mortality; D008297:Male; D011379:Prognosis; D006435:Renal Dialysis / Q000191:economics; D015996:Survival Rate