Integrated CKD Care Model Cuts ED Visits by 30%, Boosts Specialized Treatment

The interdisciplinary model combined a clinical registry with coordinated care from a team of specialists.

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After implementing an interdisciplinary care model for managing chronic kidney disease (CKD), hospital admissions dropped by 26% and emergency department (ED) visits decreased by 30%, according to a Mayo Clinic study published in Kidney360. The reductions in acute care needs were statistically significant, supporting the benefit of the clinic's comprehensive approach in managing patients more effectively in outpatient settings.

Conducted as a retrospective cohort analysis, the study examined 534 patients enrolled in a specialized CKD clinic in Minnesota between March 2021 and May 2022. The interdisciplinary model combined a clinical registry with coordinated care from a team of specialists, emphasizing evidence-based pathways, patient education, and shared decision-making.

The median age of the participants was 73 years, and the population was predominantly White (92.5%) and male (54.3%). Nearly half of the patients (46.9%) entered the clinic at CKD stage IV, and the median estimated glomerular filtration rate (eGFR) at baseline was 26 mL/min/1.73 m², indicating significant renal impairment in many individuals.

When tracking CKD progression, most patients either remained within the same stage or progressed modestly, with a few cases showing improvement, including 2 individuals who improved from stage II to stage I. Among patients with severe kidney function decline (eGFR < 20 mL/min/1.73 m²) by the end of follow-up, nearly half received multidisciplinary support: 44.7% received dietitian services, 53.3% participated in educational sessions, and 50.0% received social work support.

The interdisciplinary clinic model significantly impacted health care utilization. Hospital admission rates dropped by 26% post enrollment (incidence rate ratio [IRR], 0.74; 95% CI, 0.60-0.91; P = .004), and ED visits decreased by 30% (IRR 0.70; 95% CI, 0.57-0.87; P = .001).

Nephrology consultations increased by 46% (IRR, 1.46; 95% CI, 1.34-1.60; P < .001), indicating improved access to specialized kidney care. Interestingly, primary care visits decreased by 22% after clinic entry (IRR, 0.78; 95% CI, 0.69-0.88; P < .001), suggesting that the clinic’s integrated care model may have reduced reliance on generalist services.

The study also found a strong relationship between social determinants of health and CKD outcomes. Physical inactivity was associated with significantly higher odds of disease progression. Patients who exercised 1 to 4 days per week had twice the odds of progression compared with those who exercised 5 or more days (OR, 2.01; P = .026), and those who did not exercise at all had even higher odds (OR, 2.21; P = .012).

Employment status was also a factor; results showed that individuals who were disabled or unemployed had an 81% higher likelihood of disease progression compared with those who were employed or retired (OR, 1.81; P = .038). These findings underscore the vital role of lifestyle and socioeconomic factors in managing CKD and tailoring effective, equitable interventions.

This study has several limitations due to its retrospective design and lack of a control group, hindering causal interpretations. Improvements in hospitalization and ED visit rates may have been affected by unmeasured external factors or natural regression to the mean. Key clinical data, such as kidney-protective therapies and dialysis initiation details, were missing, affecting outcome analysis. The authors also acknowledged potential selection bias favoring less complex patients and survivor bias, while the single-center setting restricts generalizability. Moreover, there was low representation of patients from low-resource backgrounds, and individual kidney failure risk was not standardized.

Additionally, the predominantly White study population may skew the generalizability of these findings. Other research has documented the existing racial disparities in CKD and related kidney conditions; lifetime risk of progression to kidney failure requiring kidney replacement therapy, dialysis, or kidney transplantation is more than 3-fold higher for non-Hispanic Black adults and 1.5-fold higher for Hispanic adults compared with non-Hispanic White adults.2

Overall, the study found that patients with early-stage CKD were more likely to remain stable or improve, while those with advanced CKD at entry tended to progress.1 The use of a CKD registry supported proactive care, contributing to reductions in hospitalizations, ED visits, and primary care usage. Physical activity emerged as a potentially modifiable factor associated with lower health care utilization, although its effect on kidney function requires further study.

Social determinants of health, such as employment status and socioeconomic challenges, may influence both CKD progression and health care access, underscoring the need for tailored, team-based care. The authors noted that while multidisciplinary care models show promise, inconsistent outcomes across studies point to the need for standardized implementation, extended follow-up, and improved patient engagement to realize their full benefit.

References

1. Mateo Chavez MB, Moran-Melendez A, Salter L, et al. Impact of an interdisciplinary chronic kidney disease clinic on disease progression, healthcare use, and social determinants of health. Kidney360. Published online February 18, 2025. doi:10.34067/KID.0000000734

2. Cusick MM, Tisdale RL, Adams AS, et al. Balancing efficiency and equity in population-wide CKD screening. JAMA Netw Open. 2025;8(4):e254740. doi:10.1001/jamanetworkopen.2025.4740