Original Investigation
Pathogenesis and Treatment of Kidney Disease
Improving Care Coordination Between Nephrology and Primary Care: A Quality Improvement Initiative Using the Renal Physicians Association Toolkit

https://doi.org/10.1053/j.ajkd.2014.06.031Get rights and content

Background

Individuals at risk for chronic kidney disease (CKD), including those with diabetes mellitus and hypertension, are prevalent in primary care physician (PCP) practices. A major systemic barrier to mitigating risk of progression to kidney failure and to optimal care is failure of communication and coordination among PCPs and nephrologists.

Study Design

Quality improvement. Longitudinal practice-level study of tool-based intervention in nephrology practices and their referring PCP practices.

Setting & Participants

9 PCP and 5 nephrology practices in Philadelphia and Chicago.

Quality Improvement Plan

Tools from Renal Physicians Association toolkit were modified and provided for use by PCPs and nephrologists to improve identification of CKD, communication, and comanagement.

Outcomes

CKD identification, referral to nephrologists, communication among PCPs and nephrologists, comanagement processes.

Measurements

Pre- and postimplementation interviews, questionnaires, site visits, and monthly teleconferences were used to ascertain practice patterns, perceptions, and tool use. Interview transcripts were reviewed for themes using qualitative analysis based on grounded theory. Chart audits assessed CKD identification and referral (PCPs).

Results

PCPs improved processes for CKD identification, referral to nephrologists, communication, and execution of comanagement plans. Documentation of glomerular filtration rate was increased significantly (P = 0.01). Nephrologists improved referral and comanagement processes. PCP postintervention interviews documented increased awareness of risk factors, the need to track high-risk patients, and the importance of early referral. Final nephrologist interviews revealed heightened attention to communication and comanagement with PCPs and increased levels of satisfaction among all parties.

Limitations

Nephrology practices volunteered to participate and recruit their referring PCP practices. Audit tools were developed for quality improvement assessment, but were not designed to provide statistically significant estimates.

Conclusions

The use of specifically tailored tools led to enhanced awareness and identification of CKD among PCPs, increased communication between practices, and improvement in comanagement and cooperation between PCPs and nephrologists.

Section snippets

Methods

The Mayo Clinic Institutional Review Board determined that this quality improvement study (ID 09-003536) was exempt, and it was approved by the clinical leadership of the practices, whose experience is reported. We investigated nephrology and primary care practices, testing the intervention of providing tools specifically created to improve CKD identification, referral, communication, and comanagement. The experiment included 9 PCP and 5 nephrology practices over 12 to 15 months and concluded

Results

Demographic characteristics of participating practices were derived from site visits and preintervention questionnaires and are presented in Tables 2 and 3. Location was urban or suburban and practices were either group single specialty or solo; numbers of physicians and years in practice varied widely. Nephrologists’ first CKD visit averaged 40 minutes, with 20 minutes for follow-up, and PCPs estimated 35 minutes for first visit, with 20 minutes for follow-up. CKD management styles varied.

Discussion

In this study, the use of specifically tailored tools was associated with enhanced awareness and identification of CKD among PCPs and led to increased communication and improvement in comanagement and cooperation between PCPs and nephrologists.

The PCP practices improved CKD identification, referral to nephrologists, communication, and execution of comanagement plans. Nephrologists improved referral and comanagement processes. Postintervention interviews of PCPs documented increased awareness of

Acknowledgements

This work was presented as an abstract at the American Society of Nephrology’s Annual Meeting in San Diego, CA, October 30 to November 4, 2012.

The authors thank Rebecca J. Schmidt, DO, for critical review of the manuscript.

Support: This study was funded by the Renal Physicians Association from an unrestricted education grant from Abbott Laboratories. Abbott Laboratories had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and

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