Outcomes of stage 4 & 5 chronic kidney disease patients attending 2 different models of outpatient care.

INTERVENTION: Nurse‐led multidisciplinary Chronic Kidney Disease outpatient clinic A Nurse practitioner will coordinate the clinic, review patients and refer to other members of the multidisciplinary team as appropriate. Patients will follow a nurse‐implemented, nephrologist‐endorsed clinical pathway addressing key performance indicators. Patients will be reviewed in the nurse led clinic at baseline and 6 months post baseline. Additionally, the Nurse Practitioner will contact the patient by 'phone at 3 and 9 months post baseline. A written record of each visit will be sent to the patient's own nephrologist &/or GP. CONDITION: Chronic Kidney Disease PRIMARY OUTCOME: To assess the economic implications of a single, nephrologist‐led versus multiple, nurse‐led multidisciplinary outpatient clinic for the management of chronic kidney disease stage IV & V patients. ; Economic benefits of both clinic methodologies will be assessed via the improved patient outcomes including better prepared patients with timely insertion of dialysis access (thereby offsetting both the costs of temporary dialysis access and the increased hospitalization costs of complications related to temporary access), increased use of home therapies over hospital or centre‐based therapies and potentially slowing the progression of CKD (thereby offsetting time on dialysis). The NET economic benefit or lost of each MDCKD clinic will be derived from the difference between the estimated cost of the clinic (fixed staffing and hotel costs) and the calculated economic benefits that would be realized based on the key clinical outcomes from the clinics. ; Econom ic implications are from the point of view of the hospital. SECONDARY OUTCOME: comparison of blood pressure control between nurse‐led & physician‐led MD OP CKD clinics ; ; Blood pressure measurement will be taken at baseline and 12 months post baseline visit in both groups. The proportion of patients in each group achieving clinic blood pressure <140/90 will be compared. comparison of calcium/phosphate control & metabolic bone disease control between nurse‐led & physician‐led MD OP CKD clinics ; ; Calcium, phosphate & PTH will be measured at baseline and 12 months post baseline visit. The proportion of patients in each group with these measurements within the recommended CARI guidelines 2005 and the current KDIGO 2009 guidelines will be compared. comparison of conventional cardiovascular risk factors including lipid control, the use of anti platelet therapy & statins between nurse‐led & physician‐led MD OP CKD clinics. ; Medication taken by patients in both groups will be recorded at baseline and at 12 months post baseline visit. The proportion of patients in each group on nephro‐protective antihypertensives ‐ ACE‐inhibitors and Angiotensin receptor blockers will be compared. The proportion of patients on known risk‐reduction strategies: anti‐platelet therapy and statins will be compared between groups. comparison of haemoglobin between nurse‐led & physician‐led MD OP CKD clinics ; ; ; MDRD‐eGFR will be assessed at baseline and at 12 months post baseline visit (blood test) in both groups to assess progression of renal failure. comparison of timely placement of permenant dialysis access between the nurse‐led and physician‐led MD OP CKD clinics. ; ; The existence, creation date and type of dialysis access will be recorded at 12 months post baseline visit. ; ; The commencement date of dialysis will be recorded at 12 months post baseline visit. ; ; INCLUSION CRITERIA: Patients with Chronic Kidney Disease Stage IV & V attending Sir Charles Gairdner Hospital CKD OP clinic ; Haemoglobin will be measured at baseline and at 12 months post baseline visit in both groups. The proportion of patients in each group with haemoglobin <10g/dL will be compared. comparison of nutrition status between nurse‐led & physician‐led MD OP CKD clinics. Serum albumin & CRP will be measured at baseline and at 12 months post baseline in both groups. The proportion of patients in each group with albumin below normal limits and with CRP out of normal range will be compared. Weight, height, body mass index and waist circumference will be measured at baseline and 12 months in both groups and results compared. A patient generated subjective global assessment will be completed at baseline and 12 months post baseline in both groups and results will be compared. Dietician assessment will occur at baseline and at 12 months in both groups. The proportion of patients with malnutrition as assessed by the dietician will be compared in each group. comparison of progression of renal failure between nurse‐led and physician‐led MD OP CKD clinics ; The proportion of patients achieving and/or commencing dialysis with permanent dialysis access will be compared between group 1 & group 2 To compare the patient dialysis modality choice, including choice of home‐based therapy or palliative care between the nurse‐ led and physician‐led MD OP CKD clinics. ; The patients dialysis modality, whether the dialysis is performed in a health care facility or at home, and whether palliative care is initiated will be recorded at 12 months post baseline visit.