Clinical Studies
Effects of multidisciplinary case management in patients with chronic renal insufficiency,

https://doi.org/10.1016/S0002-9343(98)00329-5Get rights and content

Abstract

PURPOSE: Though case management has been recommended to improve the outcomes of patients with costly or morbid conditions, it has seldom been studied in controlled trials. We performed a randomized, controlled clinical trial of an intensive, multidisciplinary case management program for patients with chronic renal insufficiency and followed patients for 5 years.

PATIENTS AND METHODS: We enrolled 437 primary-care patients (73% of those eligible) with chronic renal insufficiency (estimated creatinine clearance consistently <50 mL/min with the last serum creatinine level >1.4 mg/dL) who were attending an urban academic general internal medicine practice. The intensive case management, administered during the first 2 years after enrollment, consisted of mandatory repeated consultations in a nephrology case management clinic staffed by two nephrologists, a renal nurse, a renal dietitian, and a social worker. Control patients received usual care. Primary outcome measurements included serum creatinine level, estimated creatinine clearance, health services use, and mortality in the 5 years after enrollment. Secondary measures included use of renal sparing and potentially nephrotoxic drugs.

RESULTS: There were no differences in renal function, health services use, or mortality in the first, second, or third through fifth years after enrollment. There were significantly more outpatient visits among intervention patients, mainly because of the added visits to the nephrology case management clinic. There were also no significant differences in the use of renal sparing or selected potentially nephrotoxic drugs. The annual direct costs of the intervention were $89,355 ($484 per intervention patient).

CONCLUSION: This intensive, multidisciplinary case-management intervention had no effect on the outcomes of care among primary-care patients with established chronic renal insufficiency. Such expensive and intrusive interventions, despite representing state-of-the-art care, should be tested prospectively before being widely introduced into practice.

Section snippets

Study site and subjects

This study was approved by the Indiana University Institutional Review Board. Patients were recruited from the general medicine practice of the Regenstrief Health Center, a multispecialty outpatient facility affiliated with, and located adjacent to, Wishard Memorial Hospital, an urban public teaching hospital. The general medicine practice has been the site of many randomized trials of health services interventions in primary care 32, 33, 34, 35. At the time of this study, it was divided into

Results

Enrollment began in June 1989 and continued for 2 years. During this time, 597 eligible patients kept general medicine practice appointments. Of these, 437 (73%) agreed to participate in the study and completed in-home interviews. Of the 160 patients not enrolled, 154 (96%) refused participation; for the remaining six (4%) the patient’s physician deemed the study inappropriate for the patient. Of the 437 enrolled patients, 206 (47%) received primary care in the two general medicine practice

Discussion

This intensive and expensive multidisciplinary case-management intervention had no important effects on renal dysfunction, health-care utilization, or mortality among a cohort of urban patients with established chronic renal insufficiency. Moreover, there were few demonstrable effects of the intervention on the management of intervention patients despite frequent and direct communications between the study nephrologists and the patients’ primary care physicians. However, a substantial

Acknowledgements

We gratefully thank Jane Rust, RN, nursing unit manager of the general medicine practice, for her unflagging support of our research efforts; Mary Robbins-Nierste for her support in establishing the nephrology case management clinic, and especially the physicians, nurses, nurses’ aids, and Regenstrief clinic clerks for their continued support of this and other research efforts. In addition, we wish to acknowledge Karen Graves, Connie Summitt, Paula Dahr, and Beatrice Schalter who formed the

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    Supported in part by grants from The Indianapolis Health Foundation (FCL), The Indianapolis Foundation (LEH, WMT), The Picker-Commonwealth Program for Patient-Centered Care (LEH), and The Agency for Health Care Policy and Research (HS04996, HS05626, HS07632, HS07719, HS07763, and HS09083) (WMT).

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