ABSTRACT
BACKGROUND: In developing countries, renal specialists are scarce and physician-to-patient contact time is limited. While conventional hospital-based, physician-oriented approach has been the main focus of chronic kidney disease (CKD) care, a comprehensive multidisciplinary health care program (Integrated CKD Care) has been introduced as an alternate intervention to delay CKD progression in a community population. The main objective is to assess effectiveness of Integrated CKD Care in delaying CKD progression. METHODS: We carried out a community-based, cluster randomized controlled trial. Four hundred forty-two stage 3-4 CKD patients were enrolled. In addition to the standard treatments provided to both groups, the patients in the intervention group also received "Integrated CKD Care". This was delivered by a multidisciplinary team of hospital staff in conjunction with a community CKD care network (subdistrict healthcare officers and village health volunteers) to provide group counseling during each hospital visit and quarterly home visits to monitor compliance with the treatment. Duration of the study was 2 years. The primary outcome was difference of mean eGFR between the intervention and the control groups over the study period. RESULTS: The mean difference of eGFR over time in the intervention group was significantly lower than the control group by 2.74 ml/min/1.73 m2 (95%CI 0.60-4.50, p = 0.009). Seventy composite clinical endpoints were reported during the study period with significantly different incidences between the control and the intervention groups (119.1 versus 69.4 per 1000 person-years; hazard ratio (HR) 0.59, 95% CI 0.4-0.9, p = 0.03). CONCLUSION: Integrated CKD Care can delay CKD progression in resource-limited settings. TRIAL REGISTRATION: ( NCT01978951 ). Prospectively registered as of December 8, 2012.
Subject(s)
Delivery of Health Care/methods , Glomerular Filtration Rate , House Calls , Patient Compliance , Patient Education as Topic , Renal Insufficiency, Chronic/therapy , Aged , Community Health Workers , Disease Management , Disease Progression , Female , Humans , Male , Middle Aged , Nephrology , Patient Care Team , Proportional Hazards Models , Renal Insufficiency, Chronic/metabolism , Rural Population , Severity of Illness Index , ThailandABSTRACT
Introduction: An integrated care program for chronic kidney disease (CKD) in Thailand has shown its effectiveness in delaying the decline in kidney function, as evidenced by the Effectiveness of Integrated Care on Delaying Progression of Stages 3 to 4 CKD in Rural Communities of Thailand (ESCORT-1) randomized control trial and the ESCORT-2 prospective cohort study. Designed for sustainability within the primary healthcare system, the program optimizes the use of the existing workforce by fostering collaboration among local multidisciplinary care teams (MDCTs) and community care networks (CCNs). Methods: A Markov model with a lifetime horizon was used to conduct a cost-utility analysis from a societal perspective. Individual participant level data from ESCORT studies, national registries, and relevant literature were used to estimate model parameters. A budget impact analysis from the payer's perspective was also assessed over a 5-year period. Results: The integrated care program yielded a dominant result with 1.84 quality-adjusted life years (QALYs) gained with "less" lifetime cost, resulting in a negative incremental cost-effectiveness ratio (ICER). Probabilistic analysis showed that the intervention being cost-effective almost 100% of the time at the local willingness-to-pay threshold. The intervention maximized cost-effectiveness when delivered as early as possible, both in terms of age and stage. The budget impact analysis estimated that the introduction of the intervention could save about 7% of the Thai government's total health expenditure or 205 billion Thai-Baht ($5.9 billion) over 5 years with cost savings beginning from the third year onwards. Conclusion: The integrated care program for CKD offers potential benefits and cost savings for patients, caregivers, and payers. Future efforts should focus on the screening and implementation processes across various regions and healthcare settings.