Effect of a change in the eligibility criteria for multidisciplinary kidney care

Background — We examined the effect of a change in the eligibility criteria for multidisciplinary care implemented across Ontario, Canada on April 1, 2016 (criteria moved from an eGFR ≤33.4 mL/min/1.73 m2 to 2-year kidney failure risk ≥10%, which incorporates assessment of proteinuria, or an eGFR <15).

Methods — Population-based, interrupted time series analysis using administrative healthcare databases that included adults with an outpatient eGFR ≤33.4 mL/min/1.73 m2 followed by a nephrologist (n=97,299). We examined multidisciplinary clinic and nephrologist visits, dialysis-related outcomes, hospital encounters and mortality by monthly interval between October 1, 2013 and February 1, 2020. Autoregressive integrated moving average models tested for level (immediate) and slope (over time) changes in outcomes after the intervention and were fit on pre-intervention change data for projected trends.

Results — Post intervention, there was a significant monthly decline in the multidisciplinary clinic visit rate of 1.49 visits per 100 p-y (95% CI: -2.83 to -0.14) and a significant monthly increase in the proportion of patients with a referral to multidisciplinary care within <1 year prior to starting dialysis (i.e., late referral) (positive slope change 0.67%; 95%: CI 0.06 to 1.28). The intervention was not associated with significant changes in the proportion of patients initiating dialysis, initiating dialysis with a central venous catheter or during a hospitalization, or utilizing home dialysis, nor in the rate of nephrologist visits. Immediately post intervention, there were small, significant increases in mortality and hospital encounters, but importantly, no monthly (slope) change in mortality and a significant negative monthly change in hospital encounters (-0.24 encounters per 100 person years; 95% CI: -0.38 to -0.09).

Conclusions — Changing the eligibility criteria for multidisciplinary kidney care from an eGFR ≤33.4 mL/min/7.73 m2 to a 2-year kidney failure risk ≥10% or an eGFR <15 mL/min/1.73 m2 resulted in significantly fewer patients receiving such care without negatively impacting important clinical outcomes.