Molnar Amber O, Nash Danielle M, Emblem Jennifer, Bota Sarah, McArthur Eric, Luo Bin, Liu Yaqing, Garg Amit X, Blake Peter G, Brimble K Scott
Division of Nephrology, Department of Medicine, McMaster University, Hamilton, ON, Canada.
St. Joseph's Hospital, Hamilton, ON, Canada.
Can J Kidney Health Dis. 2023 Nov 17;10:20543581231212134. doi: 10.1177/20543581231212134. eCollection 2023.
Guidelines in Ontario, Canada, recommend timely referral for multidisciplinary kidney care to facilitate planned dialysis initiation. Many patients do not receive recommended multidisciplinary kidney care prior to dialysis.
To better understand why this gap in pre-dialysis care exists, we conducted a study to describe the pathways by which patients initiate maintenance dialysis.
A retrospective cohort study.
Population-based, using health care administrative databases from Ontario, Canada.
Adults initiating maintenance dialysis from April 2016 to March 2019.
Patients were grouped based on whether they received recommended multidisciplinary kidney care prior to dialysis initiation (at least 1 year of care with at least 2 visits). For those who did not receive recommended care, we grouped patients as having no identified care gap or into the following groups: (1) lack of timely chronic kidney disease (CKD) screening, (2) late nephrology referral (<1 year), or (3) late or no referral for multidisciplinary kidney care among patients followed by a nephrologist for at least 1 year.
A total of 9216 patients were included with a mean (standard deviation) age of 66 (15) years, and 61.5% were male. Of the total, 896 (9.7%) patients died, 7671 (83.2%) remained on dialysis at 90 days, and 649 (7.0%) had stopped dialysis due to kidney function recovery within 90 days. Of the 9216 patients, 5434 (59%) had not received recommended multidisciplinary kidney care. Among those without recommended care, there were 2251 (41.4%) patients with no identified care gaps, 1351 (24.9%) patients with a lack of timely CKD screening, 359 (6.6%) patients with late nephrology referral, and 1473 (27.1%) patients with late or no referral for multidisciplinary kidney care.
We could not determine if patients were referred but declined multidisciplinary kidney care.
More than half of patients had not received recommended multidisciplinary kidney care. Many patients experienced an acute decline in kidney function, which may not be preventable, but in others, there were missed opportunities for CKD screening or early referral to nephrology, or at the level of nephrology practice for early referral for multidisciplinary care. This work could be used to inform policies aimed at improving increased uptake of multidisciplinary kidney care prior to dialysis.
加拿大安大略省的指南建议及时转诊以获得多学科肾脏护理，以促进有计划的透析开始。许多患者在透析前未接受推荐的多学科肾脏护理。
为了更好地理解透析前护理中为何存在这一差距，我们开展了一项研究来描述患者开始维持性透析的途径。
一项回顾性队列研究。
基于人群，使用加拿大安大略省的医疗保健管理数据库。
2016年4月至2019年3月开始维持性透析的成年人。
根据患者在开始透析前是否接受了推荐的多学科肾脏护理（至少1年护理且至少2次就诊）进行分组。对于未接受推荐护理的患者，我们将其分为未发现护理差距组或以下几组：（1）缺乏及时的慢性肾脏病（CKD）筛查，（2）肾病转诊延迟（<1年），或（3）在肾病专家随访至少1年的患者中，多学科肾脏护理转诊延迟或未转诊。
共纳入9216例患者，平均（标准差）年龄为66（15）岁，男性占61.5%。其中，896例（9.7%）患者死亡，7671例（83.2%）在90天时仍在透析，649例（7.0%）在90天内因肾功能恢复而停止透析。在9216例患者中，5字434例（59%）未接受推荐的多学科肾脏护理。在未接受推荐护理的患者中，2251例（41.4%）未发现护理差距，1351例（24.9%）缺乏及时的CKD筛查，359例（6.6%）肾病转诊延迟，1473例（27.1%）多学科肾脏护理转诊延迟或未转诊。
我们无法确定患者是否被转诊但拒绝了多学科肾脏护理。
超过一半的患者未接受推荐的多学科肾脏护理。许多患者肾功能急剧下降，这可能无法预防，但在其他患者中，存在CKD筛查或早期转诊至肾病科的错失机会，或在肾病科实践层面存在早期转诊至多学科护理的错失机会。这项工作可用于为旨在提高透析前多学科肾脏护理接受率的政策提供信息。
