Kaiser Permanente, Institute for Health Research, 10065 E. Harvard Avenue, Suite 300, Denver, CO 80231, USA.
Clin J Am Soc Nephrol. 2011 Apr;6(4):704-10. doi: 10.2215/CJN.06610810. Epub 2011 Jan 27.
A multidisciplinary team (MDT) approach to chronic kidney disease (CKD) may help optimize care of CKD and comorbidities. We implemented an MDT quality improvement project for persons with stage 3 CKD and comorbid diabetes and/or hypertension. Our objective was to decrease the rate of decline of GFR.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We used a 4-year historical cohort to compare 1769 persons referred for usual nephrology care versus 233 referred for MDT care within an integrated, not-for-profit Health Maintenance Organization (HMO). Usual care consisted of referral to an outside nephrologist. The MDT consisted of an HMO-based nephrologist, pharmacy specialist, diabetes educator, dietitian, social worker, and nephrology nurse. Both groups received usual primary care. The primary outcome was rate of decline of GFR. Secondary outcomes were LDL, hemoglobin A1c, and BP.
In multivariate repeated-measures analyses, MDT care was associated with a mean annual decline in GFR of 1.2 versus 2.5 ml/min per 1.73 m(2) for usual care. In stratified analyses, the significant difference in GFR decline persisted only in those who completed their referrals. There were no differences in the secondary outcomes between groups.
In this integrated care setting, MDT care resulted in a slower decline in GFR than usual care. This occurred despite a lack of significant differences for secondary disease-specific measures, suggesting that other differences in the MDT population or care process accounted for the slower decline in GFR in the MDT group.
多学科团队（MDT）治疗慢性肾脏病（CKD）可有助于改善 CKD 及合并症的治疗。我们针对患有 3 期 CKD 且合并糖尿病和/或高血压的患者，实施了一项 MDT 质量改进项目。我们的目标是降低肾小球滤过率（GFR）的下降速度。
设计、地点、参与者和测量方法：我们使用了 4 年的历史队列，比较了在一家综合性非营利性健康维护组织（HMO）中，1769 名接受常规肾脏病护理的患者与 233 名接受 MDT 护理的患者。常规护理包括将患者转介给外部肾病专家。MDT 由 HMO 内部的肾病专家、药剂师、糖尿病教育者、营养师、社会工作者和肾病护士组成。两组均接受常规初级保健。主要结果是 GFR 下降率。次要结果为 LDL、糖化血红蛋白（HbA1c）和血压（BP）。
在多变量重复测量分析中，MDT 护理组的 GFR 年平均下降速度为 1.2ml/min/1.73m²，而常规护理组为 2.5ml/min/1.73m²。分层分析显示，只有完成转诊的患者中，GFR 下降的差异具有统计学意义。两组在次要结局方面无差异。
在这种综合治疗环境中，MDT 护理较常规护理使 GFR 下降速度更慢。尽管在次要的疾病特异性指标方面没有显著差异，但这表明 MDT 组中人群或治疗过程的其他差异导致了 GFR 下降速度较慢。
