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Effectiveness of Integrated CKD Care Program in CKD Health Promotion Organization of the National CKD Preventive Project-- A 4-Year Experience in Kaohsiung Medical University Hospital (KMUH), Taiwan
Shu-Li Wang, Shih-Ming Hsiao, Shang-Jyh Hwang, Jer-Ming Chang, Hung-Chun Chen
Kaohsiung Medical University Hospital and Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan.

Background:
The burden of ESRD and CKD on public health and medical expenditures draw the government attention in Taiwan. To prevent the steady growing of the ESRD populations and to ensure a better care of CKD patients, a pilot study from KMUH was instituted in 2002 to set up an integrated care program for CKD patients within hospitals, and then a national CKD preventive project was implemented in 2003 through establishment of organizations to execute the CKD preventive project. The aim of this study is to evaluate the progress in effectiveness of this integrated CKD care program in the pioneer hospital, the KMUH during the 4 years period.

Method:
From Nov, 2002 to Aug, 2006, totally 1,394 patients (766 males, 54.9%, mean age of 60.4ｱ14.3 years) who had chronic renal failure and fitted the definition of CKD stage 3-5 based on NKF classifications were recruited into the care program. There were 309 patients (males 51.8%, mean age 60.3ｱ13.4 years) reached ESRD. The annual changes of the effectiveness of care program on the adequate preparation for renal replacement therapy (RRT), evaluated by indicators as: 1) percentage of patients choosing CAPD, 2) average Hct at initiation of dialysis, 3) percentage of EPO used, 4) percentage of HD patients with arteriovenous shunt created before first HD, 5) percentage of HD patients receiving first HD without hospitalization, were studied. Descriptive and inferential statistical analyses for trend with p value less than 0.05 was considered as significant.

Results:
The outcomes of the 309 patients entering RRT were 85.9% on HD, 13.8% on peritoneal dialysis, and 0.3% taking renal transplantation. The percentage of patients choosing CAPD were 18.8%, 16.2%, 11.5%, 12.7% each year from 2003 to 2006, respectively (p=0.39). The average Hct at initiation of dialysis were 23.9%, 26.2%, 26.7%, and 25.2%, respectively (p=0.035). The percentage of patients receiving EPO treatment also increased (68.8%, 94.6%, 80.4%, and 83.0%, respectively, p=0.48). The percentage of patients with well prepared arteriovenous shunt for first HD also increased significantly by years (38.5%, 46.8%, 63.6%, and 63.0%, respectively, p=0.018), and the percentage of patients entering dialysis without hospitalization showed increasing by years (30.8%, 30.6%, 38.3%, and 45.7%, p=0.05) too.

Conclusion:
The results confirm the effectiveness of integrated CKD care program in the past 4 years. There is significant improvement of the preparedness for initiation of dialysis therapy in advanced CKD patients reaching ESRD.

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