Levin A, Lewis M, Mortiboy P, Faber S, Hare I, Porter E C, Mendelssohn D C
St Paul's Hospital, University of British Columbia, Vancouver, Canada.
Am J Kidney Dis. 1997 Apr;29(4):533-40. doi: 10.1016/s0272-6386(97)90334-6.
A 1993 National Institutes of Health Consensus statement stressed the importance of early medical intervention in predialysis populations. Given the need for evidence-based practice, we report the outcomes of predialysis programs in two major Canadian cities. The purpose of this report was to determine whether the institution of a multidisciplinary predialysis program is of benefit to patients, and to analyze those factors that are important in actualizing those benefits. Data from two different studies is presented: (1) a prospective, nonrandomized cohort study comparing patients who were or were not exposed to an ongoing multidisciplinary predialysis team (St Paul's Hospital) and (2) a retrospective review of outcomes before and after the institution of a predialysis program (The Toronto Hospital). Although created independently in major academic centers in Canada, the programs both aimed to reduce urgent dialysis starts, improve preparedness for dialysis, and improve resource utilization. The Vancouver study was able to demonstrate significantly fewer urgent dialysis starts (13% v 35%; P < 0.05), more outpatient training (76% v 43%; P < 0.05), and less hospital days in the first month of dialysis (6.5 days v 13.5 days; P < 0.05). Cost savings of the program patients in 1993 are conservatively estimated to be $173,000 (Canadian dollars) or over $4,000 per patient. The Toronto study demonstrated success in predialysis access creation (86.3% of patients), but could not realize any benefit in terms of elective dialysis initiation due to well-documented hemodialysis resource constraints. We conclude that an approach to predialysis patients involving a multidisciplinary team can have a positive impact on quantitative outcomes, but essential elements for success include (1) early referral to a nephrology center, (2) adequate resources for dedicated predialysis program staff and infrastructure, and (3) available resources for patients with end-stage renal disease (ESRD) (dialysis stations). In times of economic constraints, objective data are necessary to justify resource-intensive proactive programs for patients with ESRD. Future studies should confirm and extend our observations so that optimum and cost-effective care for patients approaching ESRD is uniformly available.
1993年美国国立卫生研究院的一份共识声明强调了对透析前人群进行早期医学干预的重要性。鉴于循证医学实践的必要性，我们报告了加拿大两个主要城市的透析前项目成果。本报告的目的是确定多学科透析前项目的设立是否对患者有益，并分析实现这些益处的重要因素。本文展示了两项不同研究的数据：（1）一项前瞻性、非随机队列研究，比较了接触或未接触多学科透析前团队（圣保罗医院）的患者；（2）对透析前项目设立前后的结果进行回顾性分析（多伦多医院）。尽管这两个项目是在加拿大的主要学术中心独立开展的，但都旨在减少紧急透析的启动，提高透析准备情况，并改善资源利用。温哥华的研究表明，紧急透析启动次数显著减少（13%对35%；P<0.05），门诊培训更多（76%对43%；P<0.05），透析第一个月的住院天数更少（6.5天对13.5天；P<0.05）。据保守估计，1993年项目患者节省的费用为17.3万加元，即每位患者超过4000加元。多伦多的研究表明在建立透析前通路方面取得了成功（86.3%的患者），但由于有充分记录的血液透析资源限制，在择期透析启动方面未实现任何益处。我们得出结论，多学科团队参与的透析前患者治疗方法可对定量结果产生积极影响，但成功的关键要素包括：（1）早期转诊至肾病中心；（2）为专门的透析前项目工作人员和基础设施提供充足资源；（3）为终末期肾病（ESRD）患者提供可用资源（透析站）。在经济受限时期，客观数据对于证明为ESRD患者开展资源密集型主动项目的合理性是必要的。未来的研究应证实并扩展我们的观察结果，以便为接近ESRD的患者提供最佳且具有成本效益的护理。
