Effects of Different Models of Dialysis Care on Patient-Important Outcomes: A Systematic Review and Meta-Analysis.
Ongoing payment reform in dialysis necessitates better patient outcomes and lower costs. Suggested improvements to processes of care for maintenance dialysis patients are abundant; however, their impact on patient-important outcomes is unclear. This systematic review included comparative randomized controlled trials or observational studies with no restriction on language, published from 2000 to 2014, involving at least 5 adult dialysis patients who received a minimum of 6 months of follow-up. The effect size was pooled and stratified by intervention strategy (multidisciplinary care [MDC], home dialysis, alternate dialysis settings, and electronic health record implementation). Heterogeneity (I2) was used to assess the variability in study effects related to study differences rather than chance. Of the 1988 articles screened, 25 international studies with 74,833 maintenance dialysis patients were included. Interventions with MDC or home dialysis were associated with a lower mortality (hazard ratio [HR] = 0.72, 95% confidence interval [CI] 0.61, 0.84, I2= 41.6%; HR = 0.57, 95% CI 0.41, 0.81, I2= 89.0%; respectively) and hospitalizations (incidence rate ratio [IRR] = 0.68, 95% CI 0.51, 0.91, I2= NA; IRR = 0.88, 95% CI 0.64, 1.20, I2= 79.6%; respectively). Alternate dialysis settings also were associated with a reduction in hospitalizations (IRR = 0.41, 95% CI 0.25, 0.69, I2= 0.0%). This systematic review underscores the importance of multidisciplinary care, and also the value of telemedicine as a means to increase access to providers and enhance outcomes for those dialyzing at home or in alternate settings, including those with limited access to nephrology expertise because of travel distance.
1 Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery , Mayo Clinic, Rochester, Minnesota.
Priya
P
Ramar
2 Division of Preventive, Occupational and Aerospace Medicine, Department of Medicine, Mayo Clinic , Rochester, Minnesota.|3 Division of Psychiatry, Department of Psychiatry and Psychology, Mayo Clinic , Rochester, Minnesota.
Ahmed T
AT
Ahmed
1 Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery , Mayo Clinic, Rochester, Minnesota.|4 Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic , Rochester, Minnesota.
Zhen
Z
Wang
5 Mayo Medical School, Mayo Clinic College of Medicine , Rochester, Minnesota.|6 Johns Hopkins Bloomberg School of Public Health , Baltimore, Maryland.
Sagar S
SS
Chawla
7 Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic , Rochester, Minnesota.
Maria Lourdes Gonzalez
MLG
Suarez
1 Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery , Mayo Clinic, Rochester, Minnesota.|7 Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic , Rochester, Minnesota.
LaTonya J
LJ
Hickson
8 Mayo Clinic Libraries , Rochester, Minnesota.
Ann
A
Farrell
7 Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic , Rochester, Minnesota.
Amy W
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Williams
1 Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery , Mayo Clinic, Rochester, Minnesota.|4 Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic , Rochester, Minnesota.
Nilay D
ND
Shah
1 Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery , Mayo Clinic, Rochester, Minnesota.|2 Division of Preventive, Occupational and Aerospace Medicine, Department of Medicine, Mayo Clinic , Rochester, Minnesota.
M Hassan
MH
Murad
1 Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery , Mayo Clinic, Rochester, Minnesota.|9 Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic , Rochester, Minnesota.
Bjorg
B
Thorsteinsdottir
D019033:Delivery of Health Care, Integrated; D006801:Humans; D007676:Kidney Failure, Chronic / Q000401:mortality / Q000628:therapy; D006435:Renal Dialysis / Q000379:methods / Q000401:mortality / Q000706:statistics & numerical data; D017216:Telemedicine; D016896:Treatment Outcome
end-stage renal disease; home dialysis; multidisciplinary care; systematic review; telemedicine