Effect of a Change in the Eligibility Criteria for Multidisciplinary Kidney Care

Multidisciplinary kidney care eligibility changed from eGFR ≤33.4 ml/min per 1.73 m 2 to 2-year kidney failure risk ≥10% (includes eGFR and proteinuria). After the change, we found no difference in outcomes such as dialysis initiation, preparation for dialysis, and hospitalizations. The results of this study help guide decision making with respect to the care of patients with advanced CKD.

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

Population-based, interrupted time series analysis using administrative health care databases that included adults with an outpatient eGFR ≤33.4 ml/min per 1.73 m 2 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 were tested for level (immediate) and slope (over time) changes in outcomes after the intervention and were fit on preintervention change data for projected trends.

After intervention, there was a significant monthly decline in the multidisciplinary clinic visit rate of 1.49 visits per 100 person-years (95% confidence interval [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 before 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, using home dialysis, or in the rate of nephrologist visits. Immediately after intervention, there were small, significant increases in mortality and hospital encounters, but importantly, there was 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).

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