- Email: [email protected]
The Interdisciplinary Team: The Whole Is Larger Than the Parts
The Interdisciplinary Team: The Whole Is Larger Than the Parts Nakshatra Saxena and Dana V. Rizk Chronic kidney disease (CKD) is an emerging global health problem. Caring for CKD patients is a medical and financial challenge currently placing a significant burden on our health-care system. This creates an impetus to explore nontraditional models of care. In this article, we explore the role of interdisciplinary care clinics in managing the complex and multifaceted aspects of CKD. By having different providers work seamlessly in a synergistic and collaborative environment, there is less risk of fragmentation of care. In this patient-centered model of care, patients are empowered and engaged to achieve therapeutic targets, make lifestyle changes, and participate in decision-making. Timely referral and education delivered by advanced practitioners are 2 of the crucial elements central to the success of the interdisciplinary model. Further studies are needed to identify other key elements that would enhance the interdisciplinary approach to ensure that guideline-based therapeutic targets are reached and to define the subset of patients that would benefit the most. Innovative information technology solutions that could enhance the implementation of interdisciplinary clinics and expand their reach should be exploited. Lastly, for the paradigm shift to occur, the integrative approach should prove to be cost-effective. Q 2014 by the National Kidney Foundation, Inc. All rights reserved. Key Words: Interdisciplinary care, CKD, Chronic care model, Integrative care
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hronic kidney disease (CKD) is being described as a global health epidemic placing a major burden on the health-care system of many countries, including the United States. Approximately 13% of noninstitutionalized adults in the United States have CKD, and there is a growing population of patients being treated with renal replacement therapy (be it dialysis or transplantation).1 As of 2011, the costs for ESRD care already accounted for 6.3% of total Medicare spending.2 The traditional model of care for a CKD patient consists of shared responsibility between a primary care provider and a consulting nephrologist (Fig 1). Caring for these complex patients can be challenging because they often have multiple health problems and are on multiple medications. The National Kidney Foundation recommends referral to a nephrologist when the patient's estimated glomerular filtration rate (eGFR) is less than 30 mL/minute per 1.73 m2. The more recent Kidney Disease Improving Global Outcomes guidelines extended this recommendation to patients with urinary albumin-to-creatinine ratios of more than 300 mg/g.3-5 Despite these guidelines, consultation with a nephrologist is frequently delayed, and even when a nephrologist is consulted, there may be limited communication between providers, resulting in fragmented care. The 2013 United States Renal Data Service report indicates that 42% of patients starting dialysis had not seen a nephrologist before treatment initiation and 31.6% had seen a nephrologist for less than 1 year.2 Delayed nephrology care has been associated with reduced access to kidney transplant options, starting hemodialysis with a temporary catheter, and a high mortality rate after dialysis initiation.6,7 Transplantation may be a more physiologic and cost-effective treatment option than dialysis for patients with advanced CKD. However, even transplant recipients require extensive nephrology care. In 2005, the Kidney Disease Improving Global Outcomes guidelines included all kidney transplant patients under the definition of CKD regardless of their eGFR,3 emphasizing their need for extensive CKD care, including preparation to reintegrate into dialysis programs when
their allograft fails. The current literature suggests that transplant recipients with failing kidney allograft function are less likely to have optimal management of hypertension, anemia, and dyslipidemia as well as to undergo vascular access surgery when compared with their counterparts with failing native kidneys.8,9 In addition to its failure at achieving optimal outcomes, our current model of care has not been successful in addressing the psychosocial distress of patients and families dealing with a chronic illness such as CKD, and it has traditionally not addressed end-of-life care issues in a proactive matter.10 Physicians may not have the tools or expertise to address some of the psychosocial needs of these patients. Given the above mentioned facts and the rising cost of care, it behooves us to inspect the shortcomings of our current health-care model and to explore other avenues of care delivery. Although the best care model remains to be determined, it may lie in an interdisciplinary care clinic (Fig 2). Under this model, the heavy burden of CKD care is distributed amongst various specialists with expertise in different aspects of kidney disease care as compared with the standard model of care, in which the emphasis is on the primary care physician and the nephrologist. In the interdisciplinary model, the boundaries between the different team members become blurred, and there is increased engagement within the team but also on behalf of the patient. There is growing interest amongst nephrologists that these clinics be the standard for treating CKD.11 From Nephrology Division, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL. D.V.R. has served on advisory boards for Fresenius, Otsuka, and Amgen. She has received research grant support from Amgen, Reata Pharmaceuticals, and Bristol Myers Squibb. Address correspondence to Dana V. Rizk, MD, ZRB 629, 1720 2nd Avenue S, Birmingham, AL 35294-0007. E-mail: [email protected] Ó 2014 by the National Kidney Foundation, Inc. All rights reserved. 1548-5595/$36.00 http://dx.doi.org/10.1053/j.ackd.2014.02.011
Advances in Chronic Kidney Disease, Vol 21, No 4 (July), 2014: pp 333-337
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In fact, as early as 1994, a consensus panel by the National In another study, Bayliss and colleagues identified 2002 Institutes of Health12,13 advocated that predialysis care of CKD patients; of those identified, 233 received care from the CKD patient should be handled by a team consisting an interdisciplinary team consisting of a nephrologist, of a nephrologist, dietician, nurse, social worker, and renal clinic pharmacy specialist, diabetes nurse educator, mental health professional. To this date, the personnel kidney dietician, social worker, and nephrology nurse involved in setting up a CKD clinic vary across and over a mean observation period of 2 years. Compared within countries. with patients who received usual care, those who The positive effect of the interdisciplinary team approach benefited from a team-based interdisciplinary approach to other chronic illnesses has long been recognized. For had a slower decline in eGFR (21.2 vs 22.5 mL/minute example, interdisciplinary breast cancer clinics have per 1.73 m2) and were less likely to initiate dialysis.18 More recently, Chen and colleagues conducted a 3-year improved patient satisfaction and have been shown to prospective cohort study in Taiwan in which they included decrease the time between diagnosis and treatment initia528 matched pairs of CKD patients assigned to usual prition.14 In-patient interdisciplinary care treatment for patients with active rheumatoid arthritis had a beneficial mary care (with nephrology consultation) vs interdiscieffect on patients' emotional status and disease activity.15 plinary nephrology care consisting of a nephrologist, The effect of such an interdisciplinary approach to the nephrology nurse educator, kidney dietician, social care of CKD patients is less well established, but the curworker, pharmacy specialist, and surgeon for dialysis acrent literature seems to favor such an approach over tradicess placement and transplantation. In that study, the tional models of care. In a case control study across 2 interdisciplinary group compared with the traditional countries and 2 continents (Canada, North America; and care group had a lower rate of eGFR decline (25.1 Italy, Europe), Curtis and vs 27.3 mL/minute per colleagues showed that 1.73 m2) and a 51% reduction in mortality. Patients in when compared with tradiCLINICAL SUMMARY the interdisciplinary group tional nephrology care, were also more likely to elect exposure to a formal inter The number of patients with CKD is increasing and an peritoneal dialysis and to disciplinary CKD clinic was interdisciplinary model could be an effective option to have a vascular access rather associated with better labodeal with the complexity of their care. than a catheter at the time of ratory parameters upon Timely referral and psychosocial education, especially dialysis initiation. On the initiation of dialysis but when provided by advanced practitioners, seem to be key other hand, the frequency also, and more importantly, factors in the success of the interdisciplinary approach. and length of hospitalization with a significant survival Although the literature suggests that the interdisciplinary were no different among the advantage after the initiation team is better than the traditional model of care, optimal 2 groups.19 of dialysis. In this study, the therapeutic targets are still not being met, and there is Therefore, the balance of interdisciplinary clinic team room for improvement. evidence is in favor of an included a nurse, physician, interdisciplinary approach social worker, nutritionist, Further research should be geared toward refining the interdisciplinary care model and to explore the role of to the care of CKD patients and pharmacist. Of note, information technology in its implementation and its showing benefits after dialthe average exposure to the cost-effectiveness. ysis initiation as well as interdisciplinary clinic was before dialysis, delaying the 8 hours per patient-year as progression of CKD and opposed to 4 hours of improving mortality. When interdisciplinary clinics are nephrology care in the traditional model.16 Beyond the effects of an interdisciplinary clinic on dialysis available, as they are in parts of Canada, 91% of nephrolooutcomes, the literature suggests that such a model of care gists report using them for patient care.20 But what sets apart the interdisciplinary care from the traditional care? offers advantages to patients during the CKD phase of their In the studies showing significant delay in renal replaceillness. Hemmelgarn and colleagues identified a cohort of ment therapy, education and frequent contact with the CKD patients ($66 years of age) from Calgary, Alberta, patients were essential.18,21 Devins and colleagues Canada. Of the 6978 patients identified, 2.7% (n ¼ 187) performed a randomized controlled study involving received their care in interdisciplinary clinics and tended participants with CKD Stages 4 to 5 recruited from 15 to be older, have more comorbidities, and lower eGFR hospitals in Canada. The intervention group received than those receiving traditional care. Using propensity psychoeducational material in the form of a slide lecture scoring, these 187 patients were matched 1:1 to patients and a booklet including information about nutrition, receiving usual care. In this particular study, patients lifestyle choices, dialysis modalities, etc. Patients in this referred to the interdisciplinary clinic underwent an educaarm also received supportive follow-up phone calls every tion session at their first visit and met with a specialized third week. Patients in the control group received no strucclinic nurse, registered dietician, and social worker. From tured educational intervention. Time to dialysis was there on, they had visits and laboratory work every 1 to significantly improved in the intervention group.7 A 203 months. When compared with traditional care, an interyear follow-up of the same cohort of patients showed disciplinary approach to the care of CKD patients was assothat psychoeducational intervention also significantly ciated with improved survival. On the other hand, no improved survival.22 difference in the rate of hospitalizations was detected.17
The Interdisciplinary CKD Team
335
Figure 1. Model of usual care of the CKD patient.
When delivered effectively, education can empower motivated patients to take control of their own health. Advanced practitioners are particularly well positioned to perform educational interventions.23 They have training in nursing as well as medical and behavioral sciences, and this blend makes them good candidates to educate patients. They also maintain continuity of care with patients and follow up on educational interventions and their effect. Advanced practitioners have been shown to spend more time with patients addressing medical questions. Litaker and colleagues conducted a study in which 157 patients with hypertension and diabetes were randomly assigned to a team of a primary care physician and an advanced practitioner or to their primary physician alone. The team-treated group had better glycemic and patient satisfaction outcomes.24 Although no formal definition of an interdisciplinary team exists, studies such as the one by Litaker and colleagues implicate the advantage of having an advanced practitioner as a backbone to the integrative model. Similarly, in the MASTERPLAN study, CKD patients were randomized to receive standard care with a nephrologist vs additional intensive nurse practitioner support to implement guideline-based recommendations for lifestyle modifications and medication use. The primary outcome for the study was cardiovascular events. The intensive intervention with nurse practitioners resulted in better
blood pressure control and lipid management; less proteinuria; and increased use of antihypertensives, statins, aspirin, and vitamin D. Although the intervention had no effect on cardiovascular outcomes, it did reduce the incidence of composite renal endpoint of death, ESRD and 50% increase in SCr. The group of patients who received additional care by nurse practitioners had a lower eGFR decline by 0.45 ml/min per 1.73 m2 per year. Importantly, the difference in renal outcomes did not show up until 2 years of follow up.25 Another key component to the success of CKD care includes early referral to a nephrologist. Numerous studies have linked late referrals to increased mortality, higher hospitalizations, lack of permanent access at dialysis initiation, and fewer opportunities for transplantation.26-28 When assessing the value of different care delivery models, one cannot but address the issue of costeffectiveness. Few studies have looked at the economics of an interdisciplinary care model. In one such study, Harris and colleagues enrolled CKD patients to be randomized either to receive standard primary care with discretionary access to nephrology consultants or to be seen by an interdisciplinary team composed of a nephrologist, renal nurse, social worker, and dietician. The recommendations from the intervention team were then sent to the primary care provider to perform. The intervention lasted 2 years. At the end of the study, the
Figure 2. Model of an ideal interdisciplinary clinic.
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intensive interdisciplinary management had no effect on the outcomes of care or the mortality of CKD patients; however, it did add substantially to the health-care utilization and cost. This study has several limitations, including the fact that patients had relatively mild CKD and the interdisciplinary team relied on the primary care physician to follow up on recommendations,29 perhaps making the intervention less effective. In a more contemporary study, the Canadian Prevention of Renal and Cardiovascular Endpoints Trial randomized 236 patients to receive usual care (primary care with nephrology consultation) and 238 patients to interdisciplinary care, which consisted of a nurse-nephrologist team that implemented goal-directed therapy and initiated referrals to dieticians, social workers, diabetes educators, and other health-care professionals as needed. The interdisciplinary care focused on modification of kidney and cardiovascular risk factors. At the end of 2 years, the intervention group had a higher quality of life while using fewer health-care resources—hence resulting in lower overall cost of care. Most of the cost-saving was driven by fewer hospitalizations in the intervention group (20% vs 29% P ¼ .02).30 The structure and scope of the interdisciplinary clinics vary among studies and countries, and so does the cost of care. It remains to be seen whether these clinics are cost-effective in the United States. If we want the effect of any intervention to be substantial, then we should reach the patients early in their disease process. Information technology (IT) solutions could help bridge the gap among patients, primary providers, and nephrologists as well as interdisciplinary clinics. Although IT strategies have shown a positive effect on chronic conditions such as hypertension and diabetes, they have not been studied extensively in the CKD population. Computer decision support tools generated through electronic medical records help providers implement evidence into practice. A current ongoing trial is exploring whether the addition of a 9-point action plan (known as TRANSLATE) to computer decision support tools would enhance CKD care in the primary care setting. TRANSLATE, which stands for “set your Target, use Registry and Reminder systems, get Administrative buy-in, Network information systems, Site coordination, Local physician champion, Audit and feedback, Team approach, and Education” has been shown to be very effective in diabetes management.31 IT solutions can also be exploited at the patient level. Ong and colleagues have conceived of a “My KidneyCare Center” to support self-management strategies for patients with CKD. Here, patients can monitor their symptoms, choose their diet, have access to blood work results, and be educated about their disease and medications. Patients can access this information at home via a computer or on the go via their personal digital assistants or cell phones.32 Patients living remotely who do not have easy access to a nephrologist or to an interdisciplinary clinic are less likely to receive recommended care.33 Having innovative IT
solutions in the future may improve patient outreach and mitigate some of these barriers to care delivery. Given the current rate of growth of the CKD population and the shrinking interest in the nephrology subspecialty,34 it is imperative that we explore alternative means for the delivery of health care to our patients. Under the traditional models of care, patients are at risk of having their care fragmented and delayed. Interdisciplinary clinics offer a practical and seemingly successful alternative. We have identified key elements, such as early referral and education (especially by advanced practitioners), that make the interdisciplinary model an effective one. Innovative IT solutions may help bridge the gap between patients and the health-care system, and they may facilitate communication and cooperation among health-care providers. Future research should explore additional core components that would optimize the interdisciplinary model of care, identify the subset of patients most likely to benefit, and identify the ideal duration of interdisciplinary care. Once established, interdisciplinary CKD clinics should identify opportunities to enhance patient engagement in their own care. Patients' buy-in into their care would then enhance health-service delivery and ultimately improve outcomes. Perhaps looking at interdisciplinary care models of other chronic illnesses such as diabetes would be enlightening.35 Last but not least, at a time when the economic burden of CKD and ESRD care is soaring, interdisciplinary clinics must prove cost-effective to become the standard of care.
References 1. Coresh J, Selvin E, Stevens LA, et al. Prevalence of chronic kidney disease in the United States. J Am Med Assoc. 2007;298(17):2038-2047. 2. U.S. Renal Data System. USRDS 2013 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2013. 3. Levey AS, Eckardt KU, Tsukamoto Y, et al. Definition and classification of chronic kidney disease: a position statement from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int. 2005;67(6):2089-2100. 4. National Kidney Foundation. K/DOQI Clinical Practice Guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis. 2002;39(2 suppl 1):S1-S266. 5. Stevens PE, Levin A. Kidney Disease: Improving Global Outcomes Chronic Kidney Disease Guideline Development Work Group. Evaluation and management of chronic kidney disease: synopsis of the Kidney Disease: Improving Global Outcomes 2012 Clinical Practice Guideline. Ann Intern Med. 2013;158(11):825-830. 6. Obrador GT, Ruthazer R, Arora P, Kausz AT, Pereira BJ. Prevalence of and factors associated with suboptimal care before initiation of dialysis in the United States. J Am Soc Nephrol. 1999;10(8):1793-1800. 7. Devins GM, Mendelssohn DC, Barre PE, Binik YM. Predialysis psychoeducational intervention and coping styles influence time to dialysis in chronic kidney disease. Am J Kidney Dis. 2003;42(4):693-703. 8. Akbari A, Hussain N, Karpinski J, Knoll GA. Chronic kidney disease management: comparison between renal transplant recipients and nontransplant patients with chronic kidney disease. Nephron Clin Pract. 2007;107(1):c7-c13. 9. Dawoud D, Harms J, Williams T, Kumar V, Allon M. Predialysis vascular access surgery in patients with failing kidney transplants. Am J Kidney Dis. 2013;62(2):398-400.
The Interdisciplinary CKD Team
10. Davison SN. End-of-life care preferences and needs: perceptions of patients with chronic kidney disease. Clin J Am Soc Nephrol. 2010;5(2):195-204. 11. Filler G, Lipshultz SE. Why multidisciplinary clinics should be the standard for treating chronic kidney disease. Pediatr Nephrol. 2012;27(10):1831-1834. 12. Dixon J, Borden P, Kaneko TM, Schoolwerth AC. Multidisciplinary CKD care enhances outcomes at dialysis initiation. Nephrol Nurs J. 2011;38(2):165-171. 13. Morbidity and mortality of renal dialysis: an NIH consensus conference statement. Consensus Development Conference Panel. Ann Intern Med. 1994;121(1):62-70. 14. Gabel M, Hilton NE, Nathanson SD. Multidisciplinary breast cancer clinics. Do they work? Cancer. 1997;79(12):2380-2384. 15. Vliet Vlieland TP. Multidisciplinary team care and outcomes in rheumatoid arthritis. Curr Opin Rheumatol. 2004;16(2):153-156. 16. Curtis BM, Ravani P, Malberti F, et al. The short- and long-term impact of multi-disciplinary clinics in addition to standard nephrology care on patient outcomes. Nephrol Dial Transplant. 2005;20(1):147-154. 17. Hemmelgarn BR, Manns BJ, Zhang J, et al. Association between multidisciplinary care and survival for elderly patients with chronic kidney disease. J Am Soc Nephrol. 2007;18(3):993-999. 18. Bayliss EA, Bhardwaja B, Ross C, Beck A, Lanese DM. Multidisciplinary team care may slow the rate of decline in renal function. Clin J Am Soc Nephrol. 2011;6(4):704-710. 19. Chen YR, Yang Y, Wang SC, et al. Effectiveness of multidisciplinary care for chronic kidney disease in Taiwan: a 3-year prospective cohort study. Nephrol Dial Transplant. 2013;28(3):671-682. 20. Mendelssohn DC, Toffelmire EB, Levin A. Attitudes of Canadian nephrologists toward multidisciplinary team-based CKD clinic care. Am J Kidney Dis. 2006;47(2):277-284. 21. Strand H, Parker D. Effects of multidisciplinary models of care for adult pre-dialysis patients with chronic kidney disease: a systematic review. Int J Evid Based Healthc. 2012;10(1):53-59. 22. Devins GM, Mendelssohn DC, Barre PE, Taub K, Binik YM. Predialysis psychoeducational intervention extends survival in CKD: a 20year follow-up. Am J Kidney Dis. 2005;46(6):1088-1098. 23. Sciamanna CN, Alvarez K, Miller J, Gary T, Bowen M. Attitudes toward nurse practitioner-led chronic disease management to improve outpatient quality of care. Am J Med Qual. 2006;21(6):375-381.
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24. Litaker D, Mion L, Planavsky L, Kippes C, Mehta N, Frolkis J. Physician-nurse practitioner teams in chronic disease management: the impact on costs, clinical effectiveness, and patients' perception of care. J Interprof Care. 2003;17(3):223-237. 25. Peeters MJ, van Zuilen AD, van den Brand JA, et al. Nurse practitioner care improves renal outcome in patients with CKD. J Am Soc Nephrol. 2014;25:390-398. 26. Smart NA, Titus TT. Outcomes of early versus late nephrology referral in chronic kidney disease: a systematic review. Am J Med. 2011;124(11):1073-1080.e2. 27. Winkelmayer WC, Glynn RJ, Levin R, Mittleman MA, Pliskin JS, Avorn J. Late nephrologist referral and access to renal transplantation. Transplantation. 2002;73(12):1918-1923. 28. de Jager DJ, Voormolen N, Krediet RT, et al. Association between time of referral and survival in the first year of dialysis in diabetics and the elderly. Nephrol Dial Transplant. 2011;26(2):652-658. 29. Harris LE, Luft FC, Rudy DW, Kesterson JG, Tierney WM. Effects of multidisciplinary case management in patients with chronic renal insufficiency. Am J Med. 1998;105(6):464-471. 30. Hopkins RB, Garg AX, Levin A, et al. Cost-effectiveness analysis of a randomized trial comparing care models for chronic kidney disease. Clin J Am Soc Nephrol. 2011;6(6):1248-1257. 31. Fox CH, Vest BM, Kahn LS, et al. Improving evidence-based primary care for chronic kidney disease: study protocol for a cluster randomized control trial for translating evidence into practice (TRANSLATE CKD). Implement Sci. 2013;8:88. 32. Ong SW, Jassal SV, Porter E, Logan AG, Miller JA. Using an electronic self-management tool to support patients with chronic kidney disease (CKD): a CKD clinic self-care model. Semin Dial. 2013;26(2): 195-202. 33. Bello AK, Hemmelgarn B, Lin M, et al. Impact of remote location on quality care delivery and relationships to adverse health outcomes in patients with diabetes and chronic kidney disease. Nephrol Dial Transplant. 2012;27(10):3849-3855. 34. Parker MG, Ibrahim T, Shaffer R, Rosner MH, Molitoris BA. The future nephrology workforce: will there be one? Clin J Am Soc Nephrol. 2011;6(6):1501-1506. 35. Wiley J, Westbrook M, Long J, Greenfield JR, Day RO, Braithwaite J. Multidisciplinary diabetes team care: the experiences of young adults with type 1 diabetes. Health Expect. 2013 Dec 18 [Epub ahead of print].
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hronic kidney disease (CKD) is being described as a global health epidemic placing a major burden on the health-care system of many countries, including the United States. Approximately 13% of noninstitutionalized adults in the United States have CKD, and there is a growing population of patients being treated with renal replacement therapy (be it dialysis or transplantation).1 As of 2011, the costs for ESRD care already accounted for 6.3% of total Medicare spending.2 The traditional model of care for a CKD patient consists of shared responsibility between a primary care provider and a consulting nephrologist (Fig 1). Caring for these complex patients can be challenging because they often have multiple health problems and are on multiple medications. The National Kidney Foundation recommends referral to a nephrologist when the patient's estimated glomerular filtration rate (eGFR) is less than 30 mL/minute per 1.73 m2. The more recent Kidney Disease Improving Global Outcomes guidelines extended this recommendation to patients with urinary albumin-to-creatinine ratios of more than 300 mg/g.3-5 Despite these guidelines, consultation with a nephrologist is frequently delayed, and even when a nephrologist is consulted, there may be limited communication between providers, resulting in fragmented care. The 2013 United States Renal Data Service report indicates that 42% of patients starting dialysis had not seen a nephrologist before treatment initiation and 31.6% had seen a nephrologist for less than 1 year.2 Delayed nephrology care has been associated with reduced access to kidney transplant options, starting hemodialysis with a temporary catheter, and a high mortality rate after dialysis initiation.6,7 Transplantation may be a more physiologic and cost-effective treatment option than dialysis for patients with advanced CKD. However, even transplant recipients require extensive nephrology care. In 2005, the Kidney Disease Improving Global Outcomes guidelines included all kidney transplant patients under the definition of CKD regardless of their eGFR,3 emphasizing their need for extensive CKD care, including preparation to reintegrate into dialysis programs when
their allograft fails. The current literature suggests that transplant recipients with failing kidney allograft function are less likely to have optimal management of hypertension, anemia, and dyslipidemia as well as to undergo vascular access surgery when compared with their counterparts with failing native kidneys.8,9 In addition to its failure at achieving optimal outcomes, our current model of care has not been successful in addressing the psychosocial distress of patients and families dealing with a chronic illness such as CKD, and it has traditionally not addressed end-of-life care issues in a proactive matter.10 Physicians may not have the tools or expertise to address some of the psychosocial needs of these patients. Given the above mentioned facts and the rising cost of care, it behooves us to inspect the shortcomings of our current health-care model and to explore other avenues of care delivery. Although the best care model remains to be determined, it may lie in an interdisciplinary care clinic (Fig 2). Under this model, the heavy burden of CKD care is distributed amongst various specialists with expertise in different aspects of kidney disease care as compared with the standard model of care, in which the emphasis is on the primary care physician and the nephrologist. In the interdisciplinary model, the boundaries between the different team members become blurred, and there is increased engagement within the team but also on behalf of the patient. There is growing interest amongst nephrologists that these clinics be the standard for treating CKD.11 From Nephrology Division, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL. D.V.R. has served on advisory boards for Fresenius, Otsuka, and Amgen. She has received research grant support from Amgen, Reata Pharmaceuticals, and Bristol Myers Squibb. Address correspondence to Dana V. Rizk, MD, ZRB 629, 1720 2nd Avenue S, Birmingham, AL 35294-0007. E-mail: [email protected] Ó 2014 by the National Kidney Foundation, Inc. All rights reserved. 1548-5595/$36.00 http://dx.doi.org/10.1053/j.ackd.2014.02.011
Advances in Chronic Kidney Disease, Vol 21, No 4 (July), 2014: pp 333-337
333
334
Saxena and Rizk
In fact, as early as 1994, a consensus panel by the National In another study, Bayliss and colleagues identified 2002 Institutes of Health12,13 advocated that predialysis care of CKD patients; of those identified, 233 received care from the CKD patient should be handled by a team consisting an interdisciplinary team consisting of a nephrologist, of a nephrologist, dietician, nurse, social worker, and renal clinic pharmacy specialist, diabetes nurse educator, mental health professional. To this date, the personnel kidney dietician, social worker, and nephrology nurse involved in setting up a CKD clinic vary across and over a mean observation period of 2 years. Compared within countries. with patients who received usual care, those who The positive effect of the interdisciplinary team approach benefited from a team-based interdisciplinary approach to other chronic illnesses has long been recognized. For had a slower decline in eGFR (21.2 vs 22.5 mL/minute example, interdisciplinary breast cancer clinics have per 1.73 m2) and were less likely to initiate dialysis.18 More recently, Chen and colleagues conducted a 3-year improved patient satisfaction and have been shown to prospective cohort study in Taiwan in which they included decrease the time between diagnosis and treatment initia528 matched pairs of CKD patients assigned to usual prition.14 In-patient interdisciplinary care treatment for patients with active rheumatoid arthritis had a beneficial mary care (with nephrology consultation) vs interdiscieffect on patients' emotional status and disease activity.15 plinary nephrology care consisting of a nephrologist, The effect of such an interdisciplinary approach to the nephrology nurse educator, kidney dietician, social care of CKD patients is less well established, but the curworker, pharmacy specialist, and surgeon for dialysis acrent literature seems to favor such an approach over tradicess placement and transplantation. In that study, the tional models of care. In a case control study across 2 interdisciplinary group compared with the traditional countries and 2 continents (Canada, North America; and care group had a lower rate of eGFR decline (25.1 Italy, Europe), Curtis and vs 27.3 mL/minute per colleagues showed that 1.73 m2) and a 51% reduction in mortality. Patients in when compared with tradiCLINICAL SUMMARY the interdisciplinary group tional nephrology care, were also more likely to elect exposure to a formal inter The number of patients with CKD is increasing and an peritoneal dialysis and to disciplinary CKD clinic was interdisciplinary model could be an effective option to have a vascular access rather associated with better labodeal with the complexity of their care. than a catheter at the time of ratory parameters upon Timely referral and psychosocial education, especially dialysis initiation. On the initiation of dialysis but when provided by advanced practitioners, seem to be key other hand, the frequency also, and more importantly, factors in the success of the interdisciplinary approach. and length of hospitalization with a significant survival Although the literature suggests that the interdisciplinary were no different among the advantage after the initiation team is better than the traditional model of care, optimal 2 groups.19 of dialysis. In this study, the therapeutic targets are still not being met, and there is Therefore, the balance of interdisciplinary clinic team room for improvement. evidence is in favor of an included a nurse, physician, interdisciplinary approach social worker, nutritionist, Further research should be geared toward refining the interdisciplinary care model and to explore the role of to the care of CKD patients and pharmacist. Of note, information technology in its implementation and its showing benefits after dialthe average exposure to the cost-effectiveness. ysis initiation as well as interdisciplinary clinic was before dialysis, delaying the 8 hours per patient-year as progression of CKD and opposed to 4 hours of improving mortality. When interdisciplinary clinics are nephrology care in the traditional model.16 Beyond the effects of an interdisciplinary clinic on dialysis available, as they are in parts of Canada, 91% of nephrolooutcomes, the literature suggests that such a model of care gists report using them for patient care.20 But what sets apart the interdisciplinary care from the traditional care? offers advantages to patients during the CKD phase of their In the studies showing significant delay in renal replaceillness. Hemmelgarn and colleagues identified a cohort of ment therapy, education and frequent contact with the CKD patients ($66 years of age) from Calgary, Alberta, patients were essential.18,21 Devins and colleagues Canada. Of the 6978 patients identified, 2.7% (n ¼ 187) performed a randomized controlled study involving received their care in interdisciplinary clinics and tended participants with CKD Stages 4 to 5 recruited from 15 to be older, have more comorbidities, and lower eGFR hospitals in Canada. The intervention group received than those receiving traditional care. Using propensity psychoeducational material in the form of a slide lecture scoring, these 187 patients were matched 1:1 to patients and a booklet including information about nutrition, receiving usual care. In this particular study, patients lifestyle choices, dialysis modalities, etc. Patients in this referred to the interdisciplinary clinic underwent an educaarm also received supportive follow-up phone calls every tion session at their first visit and met with a specialized third week. Patients in the control group received no strucclinic nurse, registered dietician, and social worker. From tured educational intervention. Time to dialysis was there on, they had visits and laboratory work every 1 to significantly improved in the intervention group.7 A 203 months. When compared with traditional care, an interyear follow-up of the same cohort of patients showed disciplinary approach to the care of CKD patients was assothat psychoeducational intervention also significantly ciated with improved survival. On the other hand, no improved survival.22 difference in the rate of hospitalizations was detected.17
The Interdisciplinary CKD Team
335
Figure 1. Model of usual care of the CKD patient.
When delivered effectively, education can empower motivated patients to take control of their own health. Advanced practitioners are particularly well positioned to perform educational interventions.23 They have training in nursing as well as medical and behavioral sciences, and this blend makes them good candidates to educate patients. They also maintain continuity of care with patients and follow up on educational interventions and their effect. Advanced practitioners have been shown to spend more time with patients addressing medical questions. Litaker and colleagues conducted a study in which 157 patients with hypertension and diabetes were randomly assigned to a team of a primary care physician and an advanced practitioner or to their primary physician alone. The team-treated group had better glycemic and patient satisfaction outcomes.24 Although no formal definition of an interdisciplinary team exists, studies such as the one by Litaker and colleagues implicate the advantage of having an advanced practitioner as a backbone to the integrative model. Similarly, in the MASTERPLAN study, CKD patients were randomized to receive standard care with a nephrologist vs additional intensive nurse practitioner support to implement guideline-based recommendations for lifestyle modifications and medication use. The primary outcome for the study was cardiovascular events. The intensive intervention with nurse practitioners resulted in better
blood pressure control and lipid management; less proteinuria; and increased use of antihypertensives, statins, aspirin, and vitamin D. Although the intervention had no effect on cardiovascular outcomes, it did reduce the incidence of composite renal endpoint of death, ESRD and 50% increase in SCr. The group of patients who received additional care by nurse practitioners had a lower eGFR decline by 0.45 ml/min per 1.73 m2 per year. Importantly, the difference in renal outcomes did not show up until 2 years of follow up.25 Another key component to the success of CKD care includes early referral to a nephrologist. Numerous studies have linked late referrals to increased mortality, higher hospitalizations, lack of permanent access at dialysis initiation, and fewer opportunities for transplantation.26-28 When assessing the value of different care delivery models, one cannot but address the issue of costeffectiveness. Few studies have looked at the economics of an interdisciplinary care model. In one such study, Harris and colleagues enrolled CKD patients to be randomized either to receive standard primary care with discretionary access to nephrology consultants or to be seen by an interdisciplinary team composed of a nephrologist, renal nurse, social worker, and dietician. The recommendations from the intervention team were then sent to the primary care provider to perform. The intervention lasted 2 years. At the end of the study, the
Figure 2. Model of an ideal interdisciplinary clinic.
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Saxena and Rizk
intensive interdisciplinary management had no effect on the outcomes of care or the mortality of CKD patients; however, it did add substantially to the health-care utilization and cost. This study has several limitations, including the fact that patients had relatively mild CKD and the interdisciplinary team relied on the primary care physician to follow up on recommendations,29 perhaps making the intervention less effective. In a more contemporary study, the Canadian Prevention of Renal and Cardiovascular Endpoints Trial randomized 236 patients to receive usual care (primary care with nephrology consultation) and 238 patients to interdisciplinary care, which consisted of a nurse-nephrologist team that implemented goal-directed therapy and initiated referrals to dieticians, social workers, diabetes educators, and other health-care professionals as needed. The interdisciplinary care focused on modification of kidney and cardiovascular risk factors. At the end of 2 years, the intervention group had a higher quality of life while using fewer health-care resources—hence resulting in lower overall cost of care. Most of the cost-saving was driven by fewer hospitalizations in the intervention group (20% vs 29% P ¼ .02).30 The structure and scope of the interdisciplinary clinics vary among studies and countries, and so does the cost of care. It remains to be seen whether these clinics are cost-effective in the United States. If we want the effect of any intervention to be substantial, then we should reach the patients early in their disease process. Information technology (IT) solutions could help bridge the gap among patients, primary providers, and nephrologists as well as interdisciplinary clinics. Although IT strategies have shown a positive effect on chronic conditions such as hypertension and diabetes, they have not been studied extensively in the CKD population. Computer decision support tools generated through electronic medical records help providers implement evidence into practice. A current ongoing trial is exploring whether the addition of a 9-point action plan (known as TRANSLATE) to computer decision support tools would enhance CKD care in the primary care setting. TRANSLATE, which stands for “set your Target, use Registry and Reminder systems, get Administrative buy-in, Network information systems, Site coordination, Local physician champion, Audit and feedback, Team approach, and Education” has been shown to be very effective in diabetes management.31 IT solutions can also be exploited at the patient level. Ong and colleagues have conceived of a “My KidneyCare Center” to support self-management strategies for patients with CKD. Here, patients can monitor their symptoms, choose their diet, have access to blood work results, and be educated about their disease and medications. Patients can access this information at home via a computer or on the go via their personal digital assistants or cell phones.32 Patients living remotely who do not have easy access to a nephrologist or to an interdisciplinary clinic are less likely to receive recommended care.33 Having innovative IT
solutions in the future may improve patient outreach and mitigate some of these barriers to care delivery. Given the current rate of growth of the CKD population and the shrinking interest in the nephrology subspecialty,34 it is imperative that we explore alternative means for the delivery of health care to our patients. Under the traditional models of care, patients are at risk of having their care fragmented and delayed. Interdisciplinary clinics offer a practical and seemingly successful alternative. We have identified key elements, such as early referral and education (especially by advanced practitioners), that make the interdisciplinary model an effective one. Innovative IT solutions may help bridge the gap between patients and the health-care system, and they may facilitate communication and cooperation among health-care providers. Future research should explore additional core components that would optimize the interdisciplinary model of care, identify the subset of patients most likely to benefit, and identify the ideal duration of interdisciplinary care. Once established, interdisciplinary CKD clinics should identify opportunities to enhance patient engagement in their own care. Patients' buy-in into their care would then enhance health-service delivery and ultimately improve outcomes. Perhaps looking at interdisciplinary care models of other chronic illnesses such as diabetes would be enlightening.35 Last but not least, at a time when the economic burden of CKD and ESRD care is soaring, interdisciplinary clinics must prove cost-effective to become the standard of care.
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