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Effects of multidisciplinary case management in patients with chronic renal insufficiency∗

  • LisaE Harris
    Affiliations
    Department of Medicine, Wishard Memorial Hospital and Indiana University School of Medicine, Indianapolis, Indiana, USA (LEH, FCL, DWR, WMT)

    Regenstrief Institute for Health Care, Indianapolis, Indiana, USA (LEH, JGK)
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  • FriedrichC Luft
    Affiliations
    Department of Medicine, Wishard Memorial Hospital and Indiana University School of Medicine, Indianapolis, Indiana, USA (LEH, FCL, DWR, WMT)

    Nephrology Section, Franz Volhard Clinic, Humboldt University of Berlin, Berlin, Germany (FCL)
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  • DavidW Rudy
    Affiliations
    Department of Medicine, Wishard Memorial Hospital and Indiana University School of Medicine, Indianapolis, Indiana, USA (LEH, FCL, DWR, WMT)

    Richard L. Roudebush Veterans Affairs Medical Center (DWR, WMT), Indianapolis, Indiana, USA
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  • JosephG Kesterson
    Affiliations
    Regenstrief Institute for Health Care, Indianapolis, Indiana, USA (LEH, JGK)
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  • WilliamM Tierney
    Correspondence
    Requests for reprints should be addressed to William M. Tierney, MD, Regenstrief Institute, Sixth Floor, Regenstrief Health Center, 1001 West Tenth Street, Indianapolis, Indiana 46202
    Affiliations
    Department of Medicine, Wishard Memorial Hospital and Indiana University School of Medicine, Indianapolis, Indiana, USA (LEH, FCL, DWR, WMT)

    Regenstrief Institute for Health Care, Indianapolis, Indiana, USA (LEH, JGK)

    Richard L. Roudebush Veterans Affairs Medical Center (DWR, WMT), Indianapolis, Indiana, USA
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      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.
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