EAL

MNT: RDN in Medical Team (2015)

Citation:

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.

Study Design:

Retrospective Cohort Study

Class:

B - Click here for explanation of classification scheme.

Quality Rating:

POSITIVE: See Quality Criteria Checklist below.

Research Purpose:

To decrease the rate of decline of in glomerular filtration rate (GFR) through comprehensive, integrated, multi-disciplinary care.

Inclusion Criteria:

Adult patients with Stage 3 chronic kidney disease (CKD) and at least one of two specific co-morbid conditions.The required co-morbid conditions included diabetes mellitus or hypertension. Stage 3 CKD was defined as having at least two GFR values between 30ml and 59ml per minute per 1.73m² measured 90 days or more days apart.

Exclusion Criteria:

Dementia
Older than 90 years
Enrollment in an intensive heart failure management program
In palliative or hospice care programs
Non-English speaking.

Description of Study Protocol:

Recruitment

Historical cohort of community-dwelling members of a large, group model, integrated, not-for-profit Health Maintenance Organization (HMO) referred for nephrology care by their primary care physician during March 1, 2005 to June 1, 2009.

Design

Historical cohort.

Intervention

Comparison of persons referred for usual nephrology care vs. those referred for MDT care within an integrated, not-for-profit HMO. The MDT consisted of an HMO-based nephrologist, pharmacy specialist, diabetes educator, dietitian, social worker and nephrology nurse.

Statistical Analysis

Mixed effect modeling to assess both change in GFR and secondary outcomes as a function of participation in the QI program. Multi-variate analyses were adjusted for baseline GFR, number of GFR measurements, number of primary care visits, visit to any nephrologist, amount of follow-up time, age, race, gender, morbidity score and BMI.

Data Collection Summary:

Timing of Measurements

Baseline and four years.

Dependent Variables

Change in GFR over time: Using four variable Modification in Diet and Renal Disease equation. Final GFR was the last GFR before either the end of the project period or being censored (death, disenrollment from the health care plan or started renal replacement therapy) from the cohort
Adjusted final values of the disease-specific quality measures of LDL-Cholesterol and HbA1c
Percent time at goal blood pressure (BP) of less than 130/80mm Hg.

Independent Variables

MDT program vs. usual care.

Description of Actual Data Sample:

Initial N: N=2,002 (1,114 males, 888 females)
Age: 68 years
Ethnicity: 1,365 white, 144 African American, 493 other/unknown, 176 Hispanic, 1,460 non-Hispanic
Other relevant demographics: Equivalent in age, gender, race, ethnicity, length of follow-up and biologic values
Anthropometrics: BMI of MDT was statistically greater than usual care (P≤0.0001)
Location: Denver, CO.

Summary of Results:

Findings

MDT patients had a lower rate of of primary care visits, but were more likely to disenroll from the integrated care plan. Fewer MDT patients initiated dialysis than did usual care patients, and they had lower rates of hospitalization during follow-up.
The rate of decline in GFR was lower in the MDT group. In multi-variate repeated-measures analyses, referral to the internal MDT was associated with a mean decline in GFR of 1.2ml per minute per 1.73m² compared with a mean GFR decline of 2.5ml per minute per 1.73m² in members referred to the other three outside referral sites (P=0.0001)
In stratified analyses of patients who completed their nephrology referrals and attended at least one visit with a nephrologist vs. those who not complete their referrals, the significant difference in decline in GFR between the two groups persisted in the completed referral group but not in the group who did not complete their referrals.
There were no differences in the BP, A1c, or LDL-Cholesterol between the two groups.

Author Conclusion:

MDT care resulted in a slower decline in GFR than usual. This occurred despite a lack of significant difference for secondary disease-specific measure, suggesting that other difference in the MDT population or care process accounted for the slower decline in GFR in the MDT group.

Funding Source:

Reviewer Comments:

Quality Criteria Checklist: Primary Research
Relevance Questions
	1.	Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies)	Yes
	2.	Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about?	Yes
	3.	Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice?	Yes
	4.	Is the intervention or procedure feasible? (NA for some epidemiological studies)	Yes

Validity Questions
1.	Was the research question clearly stated?		Yes
	1.1.	Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified?	Yes
	1.2.	Was (were) the outcome(s) [dependent variable(s)] clearly indicated?	Yes
	1.3.	Were the target population and setting specified?	Yes
2.	Was the selection of study subjects/patients free from bias?		Yes
	2.1.	Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study?	Yes
	2.2.	Were criteria applied equally to all study groups?	Yes
	2.3.	Were health, demographics, and other characteristics of subjects described?	Yes
	2.4.	Were the subjects/patients a representative sample of the relevant population?	Yes
3.	Were study groups comparable?		Yes
	3.1.	Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT)	Yes
	3.2.	Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline?	Yes
	3.3.	Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.)	Yes
	3.4.	If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis?	Yes
	3.5.	If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.)	N/A
	3.6.	If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")?	N/A
4.	Was method of handling withdrawals described?		N/A
	4.1.	Were follow-up methods described and the same for all groups?	N/A
	4.2.	Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.)	N/A
	4.3.	Were all enrolled subjects/patients (in the original sample) accounted for?	N/A
	4.4.	Were reasons for withdrawals similar across groups?	N/A
	4.5.	If diagnostic test, was decision to perform reference test not dependent on results of test under study?	N/A
5.	Was blinding used to prevent introduction of bias?		Yes
	5.1.	In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate?	N/A
	5.2.	Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.)	Yes
	5.3.	In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded?	Yes
	5.4.	In case control study, was case definition explicit and case ascertainment not influenced by exposure status?	N/A
	5.5.	In diagnostic study, were test results blinded to patient history and other test results?	N/A
6.	Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described?		Yes
	6.1.	In RCT or other intervention trial, were protocols described for all regimens studied?	Yes
	6.2.	In observational study, were interventions, study settings, and clinicians/provider described?	N/A
	6.3.	Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect?	Yes
	6.4.	Was the amount of exposure and, if relevant, subject/patient compliance measured?	Yes
	6.5.	Were co-interventions (e.g., ancillary treatments, other therapies) described?	Yes
	6.6.	Were extra or unplanned treatments described?	Yes
	6.7.	Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups?	Yes
	6.8.	In diagnostic study, were details of test administration and replication sufficient?	N/A
7.	Were outcomes clearly defined and the measurements valid and reliable?		Yes
	7.1.	Were primary and secondary endpoints described and relevant to the question?	Yes
	7.2.	Were nutrition measures appropriate to question and outcomes of concern?	Yes
	7.3.	Was the period of follow-up long enough for important outcome(s) to occur?	Yes
	7.4.	Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures?	Yes
	7.5.	Was the measurement of effect at an appropriate level of precision?	Yes
	7.6.	Were other factors accounted for (measured) that could affect outcomes?	Yes
	7.7.	Were the measurements conducted consistently across groups?	Yes
8.	Was the statistical analysis appropriate for the study design and type of outcome indicators?		Yes
	8.1.	Were statistical analyses adequately described and the results reported appropriately?	Yes
	8.2.	Were correct statistical tests used and assumptions of test not violated?	Yes
	8.3.	Were statistics reported with levels of significance and/or confidence intervals?	Yes
	8.4.	Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)?	Yes
	8.5.	Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)?	Yes
	8.6.	Was clinical significance as well as statistical significance reported?	Yes
	8.7.	If negative findings, was a power calculation reported to address type 2 error?	N/A
9.	Are conclusions supported by results with biases and limitations taken into consideration?		Yes
	9.1.	Is there a discussion of findings?	Yes
	9.2.	Are biases and study limitations identified and discussed?	Yes
10.	Is bias due to study's funding or sponsorship unlikely?		Yes
	10.1.	Were sources of funding and investigators' affiliations described?	N/A
	10.2.	Was the study free from apparent conflict of interest?	Yes