Background and hypothesis In patients with moderate or severe renal disease, hospitalization is often required because of poorly controlled co-morbidities. We aimed to provide evidence that an outpatient health program involving a close collaboration between nephrologists and General Practitioners can be successful in reducing hospitalizations in non-dialysis chronic kidney disease patients.

Methods Observational cohort study on 17,036 stage 1-5 chronic kidney disease patients enrolled in the Emilia-Romagna (Italy) PIRP project between 1st April 2004 and 31st December 2015, and their 70,560 hospitalizations registered in the four years preceding and following their enrolment in the project. Interrupted Time Series analysis was used to estimate hospitalizations’ trend summarized on 4-monthly basis.

Results Among patients who survived 4 years in non-dialysis chronic kidney disease condition, a 2.9% reduction in hospitalizations was observed in the four years following the enrolment in PIRP compared to the four years previously. The change in hospitalizations’ trend was estimated at −8.09 admission per 1,000 patients and 4-month period. This decrease was mainly accountable to hospitalizations whose main diagnoses at discharge were diseases of the circulatory system and the genitourinary system (−2.68 and −4.76 admissions per 1,000 patients respectively). Patients with heart failure and those with coronary artery disease displayed large reductions in hospitalization trend (−17.08 and −9.48 admissions per 1,000 patients respectively). A reduction of hospitalizations with similar magnitude was also observed for the advanced stages of CKD.

Conclusion The implementation of an integrated public health project that provides for the early management and continuity of care of CKD patients may be a way to reduce hospitalizations, particularly those related to cardiovascular and genitourinary diagnoses.

What was known With an integrated and structured program based on the collaboration between nephrologists and General Practitioners, it is possible to better control progression and comorbidity in CKD.

This study adds By continuously following CKD patients with a close collaboration between nephrologists and General Practitioners, hospitalizations can be reduced.

Potential impact The implementation of an integrated model of outpatient management of CKD patients like the PIRP might be beneficial also on hospitals’ organization and costs, and ultimately on patients’ quality of life.

Graphical abstract

The authors have declared no competing interest.

The study was funded by the Italian Ministry of Health, RC-2023-2778789.

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

Ethics Committee of Area Vasta Emilia Centro (AVEC) gave ethical approval for this work (identification No. 341/2022/Oss/AOUBo).

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

Yes

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

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I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Yes

All data produced in the present study are available upon reasonable request to the authors