MULTIDISCIPLINARY PREDIALYSIS PROGRAMS - QUANTIFICATION AND LIMITATIONS OF THEIR IMPACT ON PATIENT OUTCOMES IN 2 CANADIAN SETTINGS

1993 National Institutes of Health Consensus statement stressed the im portance of early medical intervention in predialysis populations, Giv en the need for evidence-based practice, we report the outcomes of pre dialysis programs in two major Canadian cities, The purpose of this re port was to determine whether the institution of a multidisciplinary p redialysis program is of benefit to patients, and to analyze those fac tors that are important in actualizing those benefits, Data from two d ifferent studies is presented: (1) a prospective, nonrandomized cohort study comparing patients who were or were not exposed to an ongoing m ultidisciplinary predialysis team (St Paul's Hospital) and (2) a retro spective review of outcomes before and after the institution of a pred ialysis program (The Toronto Hospital), Although created independently in major academic centers in Canada, the programs both aimed to reduc e urgent dialysis starts, improve preparedness for dialysis, and impro ve resource utilization. The Vancouver study was able to demonstrate s ignificantly fewer urgent dialysis starts (13% v 35%; P < 0.05), more outpatient training (76% v 43%; P < 0.05), and less hospital days in t he first month of dialysis (6.5 days v 13.5 days; P < 0.05), Cost savi ngs of the program patients in 1993 are conservatively estimated to be $173,000 (Canadian dollars) or over $4,000 per patient. The Toronto s tudy demonstrated success in predialysis access creation (86.3% of pat ients), but could not realize any benefit in terms of elective dialysi s initiation due to well-documented hemodialysis resource constraints. We conclude that an approach to predialysis patients involving a mult idisciplinary team can have a positive impact on quantitative outcomes , but essential elements for success include (1) early referral to a n ephrology center, (2) adequate resources for dedicated predialysis pro gram staff and infrastructure, and (3) available resources for patient s with end-stage renal disease (ESRD) (dialysis stations). In times of economic constraints, objective data are necessary to justify resourc e-intensive proactive programs for patients with ESRD, Future studies should confirm and extend our observations so that optimum and cost-ef fective care for patients approaching ESRD is uniformly available. (C) 1997 by the National Kidney Foundation, Inc.