Department of Internal Medicine, University of Manitoba, Canada.
Nephrol Dial Transplant. 2010 Nov;25(11):3623-30. doi: 10.1093/ndt/gfq244. Epub 2010 May 12.
Observational and randomized controlled studies suggest that patients with stage 4 and 5 chronic kidney disease (CKD) derive morbidity and mortality benefit from being followed up in multidisciplinary, allied health clinics. It remains unclear how these clinics should be structured in order to optimize an efficient use of resources. The objectives of this study are (i) to describe 'human' resource utilization in an established 'traditional' multidisciplinary CKD clinic and (ii) to optimize efficiency and accountability of this multidisciplinary CKD clinic while maintaining or improving delivered quality of care.
We conducted a prospective, cohort, intervention study in the multidisciplinary CKD clinics at a university-affiliated hospital in Winnipeg, Canada. There were 480 patients identified as requiring multidisciplinary care (68% male; 32% female; 64% Caucasian, 25% First Nations, 7% Asian; mean age 61), and the majority of these were in stages 4 and 5 CKD (80%). The aetiologies of CKD included diabetes (53%), hypertension (10%) and glomerulonephritis (GN) (19%). At baseline, process engineering analyses were conducted on resource use and workflows within the clinics. The intervention entailed clinic restructuring including changes to scheduling templates and documentation format as well as standardization of practitioner roles. Cross-sectional data to serve as surrogates for quality of care and efficiency were collected 1 year pre- and post-intervention.
Optimization of clinic structure did not significantly change the cycle times among nurses, dieticians and pharmacists, but nephrologists' cycle time decreased from 13.8 min [interquartile range (IQR) 8-17] to 10.0 min (IQR 10-15) with P < 0.001. Patient throughput time decreased from 73 min (IQR 51-95) to 68.5 min (IQR 55-80). Compliance with established practice guidelines prior to clinic restructuring was 61% for BP (<130/80); 69% for haemoglobin (110-120 g/dL); 69% for ASA use; 63% for beta-blocker use; 43% for ACEi/ARB use; 64% for statin use, and did not change significantly post-intervention.
Optimization of multidisciplinary CKD clinic structure using a standard process engineering methodology improves resource utilization while maintaining (without compromising) quality of care. The delivery of care is accomplished without the need for additional resources and with decreased reliance on physician input. The methodology proposes a useful algorithm for dynamic monitoring of quality metrics for clinical care linked directly to specific allied health inputs.
观察性研究和随机对照试验表明，接受多学科联合保健诊所随访的 4 期和 5 期慢性肾脏病（CKD）患者在发病率和死亡率方面获益。目前尚不清楚为了优化资源的有效利用，这些诊所应该如何构建。本研究的目的是：（i）描述既定的“传统”多学科 CKD 诊所中的“人力”资源利用情况；（ii）在维持或提高所提供的护理质量的同时，优化该多学科 CKD 诊所的效率和问责制。
我们在加拿大温尼伯市一所大学附属医院的多学科 CKD 诊所进行了前瞻性、队列、干预研究。共有 480 名患者被确定需要多学科护理（68%为男性；32%为女性；64%为白种人，25%为第一民族，7%为亚洲人；平均年龄 61 岁），其中大多数处于 4 期和 5 期 CKD（80%）。CKD 的病因包括糖尿病（53%）、高血压（10%）和肾小球肾炎（GN）（19%）。在基线时，对诊所内的资源利用和工作流程进行了流程工程分析。干预措施包括改变排班模板和文档格式，以及规范从业者角色，从而对诊所结构进行重组。在干预前和干预后 1 年收集了作为护理质量和效率替代指标的横断面数据。
虽然诊所结构的优化并没有显著改变护士、营养师和药剂师的周期时间，但肾病医生的周期时间从 13.8 分钟（IQR 8-17）减少到 10.0 分钟（IQR 10-15），差异具有统计学意义（P < 0.001）。患者的就诊时间从 73 分钟（IQR 51-95）减少到 68.5 分钟（IQR 55-80）。在进行诊所重组之前，遵循既定的临床实践指南的情况为：血压（<130/80）为 61%；血红蛋白（110-120g/dL）为 69%；ASA 使用率为 69%；β受体阻滞剂使用率为 63%；ACEi/ARB 使用率为 43%；他汀类药物使用率为 64%，干预后这些数据没有显著变化。
使用标准的流程工程方法优化多学科 CKD 诊所的结构，可在维持（不影响）护理质量的同时提高资源利用率。在无需额外资源的情况下，减少对医生投入的依赖即可提供护理。该方法提出了一种有用的算法，用于动态监测与特定联合保健投入直接相关的临床护理质量指标。
