Effectiveness of medical compared to multidisciplinary models of care for adult persons with pre-dialysis chronic kidney disease: a systematic review.

Abstract

AIM Multidisciplinary care is a model of care that has increased in popularity. It offers opportunities for different ways of providing care. The objective of this systematic review was to compare the effectiveness of multidisciplinary care on the progression of chronic kidney disease by adult pre-dialysis patients in comparison to traditional medical care. METHODS Eleven databases were searched for material published between January 1990 to July 2009 and 37 search terms were used in different combinations. In addition, suitable journals and websites were searched as well as a hand search of reference lists in the retrieved hits from the database searches was used as well. Management tools from the Joanna Briggs Institute-Meta Analysis of Statistics Assessment and Review Instrument were used to assess the methodological quality of each of the retrieved articles that met the criteria for the review. Data extraction and synthesis was performed using the appropriate tool. RESULTS From 927 hits only four articles were finally deemed suitable for inclusion in the systematic review. Two reported the results of randomised controlled trials and the remaining two were observational studies. The data was not presented in a format that allowed a meta-analysis to be performed. One article (from 1998) argued that multidisciplinary care was not cost effective and in this study there was no difference in outcomes between multidisciplinary care and traditional care. The other three articles showed a positive impact on patient wellbeing and outcomes for those receiving multidisciplinary care, such as delay in the progression of their chronic kidney disease. Education of patients was shown to have a significant effect on the delay in time for patients initiating renal replacement therapy whether as peritoneal-dialysis, haemo-dialysis or transplantation. None of the articles reported negative effects, reduced safety or poor outcomes for the patients receiving multidisciplinary care. Well controlled blood pressure, within treatment targets, appears to be an important factor in delaying the progression of their chronic kidney disease, although this did not reach statistical significance. CONCLUSION Multidisciplinary care is deemed to be effective for adults with pre-dialysis chronic kidney disease. The effectiveness is shown as a delay in time to initiation of renal replacement therapy. Education is an important component that should be included in a multidisciplinary model of care. The education should in particular aim to increase the knowledge and understanding of the causes of ill health for people with chronic kidney disease. IMPLICATIONS FOR PRACTICE The results from the systematic review support the implementation of multidisciplinary clinics like chronic kidney disease clinics as a way to delay progression of chronic kidney disease. This model of care often includes each member of the multidisciplinary team educating the patient in their area of expertise while the nephrologists or a nurse practitioner regularly reviews and creates a management plan jointly with the patient. IMPLICATIONS FOR RESEARCH Further research needs to be conducted on the best models of education for this population, including who is ideally suited to provide the education. As none of the studies reviewed multidisciplinary care in Australian chronic kidney disease clinics, this needs to be further assessed regarding patient outcomes and wellbeing. Other outcomes of interest that require further research are the safety and cost effectiveness of multidisciplinary care as well as patients' experiences of the care and possible impacts on their independence. At present there is limited research published in this area, particularly in an Australian context.