Effects of proactive population-based nephrologist oversight on progression of chronic kidney disease: a retrospective control analysis.
BACKGROUND
Benefits of early nephrology care are well-established, but as many as 40% of U.S. patients with end-stage renal disease (ESRD) do not see a nephrologist before its onset. Our objective was to evaluate the effect of proactive, population-based nephrologist oversight (PPNO) on chronic kidney disease (CKD) progression.


METHODS
Retrospective control analysis of Kaiser Permanente Hawaii members with CKD using propensity score matching methods. We matched 2,938 control and case pairs of individuals with stage 3a CKD for the pre-PPNO period (2001-2004) and post-PPNO period (2005-2008) that were similar in other characteristics: age, gender, and the presence of diabetes and hypertension. After three years, we classified the stage outcomes for all individuals. We assessed the PPNO effect across all stages of progression with a χ2-test. We used the z-score test to assess the proportional differences in progression within a stage.


RESULTS
The progression within the post-PPNO period was less severe and significantly different from the pre-PPNO period (p = 0.027). Within the stages, there were 2.6% more individuals remaining in 3a in the post-period (95% confidence interval [CI], 1.5% to 3.8%; P value < 0.00001). Progression from 3a to 3b was 2.2% less in the post-period (95% [CI], 0.7% to 3.6%; P value = 0.0017), 3a to 4/5 was 0.2% less (95% CI, 0.0% to 0.87%; P value = 0.26), and 3a to ESRD was 0.24% less (95% CI, 0.0% to 0.66%, P value = 0.10).


CONCLUSIONS
Proactive, population-based nephrologist oversight was associated with a statistically significant decrease in progression. With enabling health information technology, risk stratification and targeted intervention by collaborative primary and specialty care achieves population-level care improvements. This model may be applicable to other chronic conditions.
Division of Nephrology, Kaiser Permanente Hawaii, Moanalua Medical Center, Honolulu, HI 96819, USA.
Brian
B
Lee
Marianne
M
Turley
Di
D
Meng
Yvonne
Y
Zhou
Terhilda
T
Garrido
Alan
A
Lau
Linda
L
Radler
D000368:Aged; D000369:Aged, 80 and over; D016022:Case-Control Studies; D016009:Chi-Square Distribution; D018450:Disease Progression; D005260:Female; D006254:Hawaii; D006801:Humans; D007676:Kidney Failure, Chronic / Q000503:physiopathology* / Q000628:therapy*; D008297:Male; D016347:Medical Records Systems, Computerized; D008875:Middle Aged; D009398:Nephrology / Q000592:standards*; D057216:Propensity Score; D012017:Referral and Consultation; D012189:Retrospective Studies; D018570:Risk Assessment