Effects of multidisciplinary case management in patients with chronic renal insufficiency

PURPOSE: Though case management has been recommended to improve the outcome s 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 wit h chronic renal insufficiency and followed patients for 5 years. PATIENTS AND METHODS: We enrolled 437 primary-care patients (73% of those e ligible) with chronic renal insufficiency (estimated creatinine clearance c onsistently <50 mL/min with the last serum creatinine level >1.4 mg/dL) who were attending an urban academic general internal medicine practice. The i ntensive case management, administered during the first 2 years after enrol lment, consisted of mandatory repeated consultations in a nephrology case m anagement clinic staffed by two nephrologists, a renal nurse, a renal dieti tian, and a social worker. Control patients received usual care. Primary ou tcome measurements included serum creatinine level, estimated creatinine cl earance, health services use, and mortality in the 5 years after enrollment . Secondary measures included use of renal sparing and potentially nephroto xic drugs. RESULTS: There were no differences in renal function, health services use, or mortality in the first, second, or third through fifth years after enrol lment. There were significantly more outpatient visits among intervention p atients, mainly because of the added visits to the nephrology case manageme nt clinic. There were also no significant differences in the use of renal s paring or selected potentially nephrotoxic drugs. The annual direct costs o f 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 esta blished chronic renal insufficiency. Such expensive and intrusive intervent ions, despite representing state-of-the-art care, should be tested prospect ively before being widely introduced into practice. Am J Med. 1998;105:464- 471, (C) 1998 by Excerpta Medica, Inc.