Interpreting Policy Effects on Multidisciplinary Kidney Care

In their recent JASN article, Molnar et al. evaluated a province-wide change in Ontario's Multi-Care Kidney Clinic funding eligibility—from an eGFR ≤33.4 ml/min per 1.73 m2 criterion to a 2-year kidney failure risk equation ≥10% or an eGFR <15—using interrupted time series analyses of 97,299 adults with CKD.1 They reported fewer multidisciplinary clinic visits after April 2016, without clear worsening in several dialysis preparation metrics, while late referral (<1 year before dialysis) showed an increasing postintervention slope.1 These findings are timely for jurisdictions considering risk-based triage. First, because the study relies on autoregressive integrated moving average–based interrupted time series models, additional detail on model specification and diagnostics would strengthen interpretability.2,3 In Tables 2–4, each model lists two parameter sets (e.g., [1, 1, 0] and [0, 12, 0]).1 Could the authors clarify whether the latter denotes a seasonal component with a 12-month period and, if so, report the seasonal orders explicitly? We also ask how autoregressive integrated moving average orders were selected (e.g., Akaike information criterion/Bayesian information criterion, autocorrelation function/partial autocorrelation function) and whether standard diagnostics supported adequacy (stationarity after differencing and residual whiteness, such as Ljung–Box tests).2,3 Given the use of routinely collected data, transparent reporting of these decisions aligns with current reporting recommendations.4 Second, late referral was expressed as a proportion among patients initiating dialysis (Figure 2).1 Because both the monthly denominator and the case mix of dialysis starters can fluctuate, it may be helpful to provide monthly counts of dialysis initiations and late referrals (overall and by risk group) and, where feasible, an absolute rate (e.g., late referrals per 100 CKD person-years) as a sensitivity analysis.2 We believe that these clarifications would further strengthen confidence in the reported policy effects and help guide implementation of risk-based multidisciplinary kidney care.