Impact of the KidneyWise toolkit on chronic kidney disease referral practices in Ontario primary care: a prospective evaluation

Abstract

ObjectivesChronic kidney disease (CKD) is common; therefore, coordination of care between primary care and nephrology is important. Ontario Renal Network’s KidneyWise toolkit was developed to provide guidance on the detection and management of people with CKD in primary care (www.kidneywise.ca). The aim of this study was to evaluate the impact of the April 2015 KidneyWise toolkit release on the characteristics of primary care referrals to nephrology.Design and settingThe study was a prospective pre-post design conducted at two nephrology sites (community site: Trillium Health Partners in Mississauga, Ontario, Canada, and academic site: St Joseph’s Healthcare in Hamilton, Ontario, Canada). Referrals were compared during the 3-month time period immediately prior to, and during a 3-month period 1 year after, the toolkit release.Primary and secondary outcome measuresThe primary outcome was the change in proportion of referrals for CKD that met the KidneyWise criteria. Additional secondary referral and quality of care outcomes were also evaluated. Multivariable logistic regression was used to evaluate preselected variables for their independent association with referrals that met the KidneyWise criteria.ResultsThe proportion of referrals for CKD among people who met the KidneyWise referral criteria did not significantly change from pre-KidneyWise to post-KidneyWise implementation (44.7% vs 45.8%, respectively, adjusted OR 1.16, 95% CI 0.85 to 1.59, p=0.36). The proportion of referrals for CKD that provided a urine albumin-creatinine ratio significantly increased post-KidneyWise (25.8% vs 43.8%, adjusted OR 1.45, 95% CI 1.06 to 1.97, p=0.02). The significant independent predictors of meeting the KidneyWise referral criteria were academic site, increased age and use of the KidneyWise referral form.ConclusionsWe did not observe any change in the proportion of appropriate referrals for CKD at two large nephrology centres 1 year after implementation of the KidneyWise toolkit.

Association of Albuminuria and Regression of Chronic Kidney Disease in Adults With Newly Diagnosed Moderate to Severe Chronic Kidney Disease

“…On the other hand, with higher albuminuria, regression becomes improbable and expedited referral for specialist care may be warranted. Although there is consensus that nephrology referral should occur once eGFR is less than 30 mL/min/1.73 m 2 (stage G4 CKD), guidelines differ regarding referral recommendations based on ACR . We found that compared with people with G3b CKD with ACR less than 3 mg/mmol (54% of the cohort), those with G3b CKD and ACR of 30 to 59 mg/mmol CKD (2% of the cohort) had 44% to 60% lower hazard rates of regression.…”

“…G4 CKD), guidelines differ regarding referral recommendations based on ACR. 8,11,12 We found that compared with people with G3b CKD with ACR less than 3 mg/mmol (54% of the cohort), those with G3b CKD and ACR of 30 to 59 mg/mmol CKD (2% of the cohort) had 44% to 60% lower hazard rates of regression. This small subset of patients with eGFR greater than 30 mL/min/1.73 m 2 (stage G3b CKD) and ACR 30 to 59 mg/mmol may benefit from earlier nephrology referral, as recommended by some (but not all) guidelines.…”

“…We found that compared with people with G3b CKD with ACR less than 3 mg/mmol (54% of the cohort), those with G3b CKD and ACR of 30 to 59 mg/mmol CKD (2% of the cohort) had 44% to 60% lower hazard rates of regression. This small subset of patients with eGFR greater than 30 mL/min/1.73 m 2 (stage G3b CKD) and ACR 30 to 59 mg/mmol may benefit from earlier nephrology referral, as recommended by some (but not all) guidelines . Although the probability of regression is reduced to a lesser extent in patients with stage G3b CKD and ACR of 3 to 29 mg/mmol (12%-29% lower hazard), their increased absolute risk of progression relative to those without albuminuria requires closer monitoring by their primary care physicians.…”

“…This small subset of patients with eGFR greater than 30 mL/min/1.73 m 2 (stage G3b CKD) and ACR 30 to 59 mg/mmol may benefit from earlier nephrology referral, as recommended by some (but not all) guidelines. 8,11,12 Although the probability of regression is reduced to a lesser extent in patients with stage G3b CKD and ACR of 3 to 29 mg/mmol (12%-29% lower hazard), their increased absolute risk of progression relative to those without albuminuria requires closer monitoring by their primary care physicians. Since patients with albuminuria that is mild or within reference range and G3b CKD comprise the largest proportion of the CKD population, these findings could result in a significant reduction of potentially inappropriate referrals, granting access to those most likely to benefit from consultation.…”

“…Viewing CKD trajectory as a 1-way path toward failure may lead to an overly pessimistic prognosis outlook for patients and health care practitioners, hindering opportunities to improve health, and result in suboptimal CKD management. Studies have found that patients are often referred to nephrology despite not meeting regional criteria, [6][7][8] possibly reflecting the belief among primary care physicians that progressive disease is inevitable. Although eGFR alone may not reliably differentiate individuals whose CKD progresses from those in whom CKD remains stable or regresses, 4,5,9,10 referral is usually triggered by reduced eGFR, even in the absence of albuminuria, while referral criteria for albuminuria vary across guidelines.…”