Renal quality outcomes framework and eGFR: impact on secondary care

Phillips, L. A.; Donovan, Kieron; Phillips, Aled Owain

doi:10.1186/1753-6561-6-s4-o44

Cited by 18 publications

(9 citation statements)

References 25 publications

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“…202 A second set of studies assessed the impact of the QOF on hospital utilisation. [199][200][201]203 This pay-for-performance scheme did not (initially) have any incentives related to outpatient referrals but did provide incentives for chronic disease management that could have impacted on referrals. The evidence is clear that it did, with a step increase in referrals to renal clinics after the introduction of an incentive to identify and manage patients with renal failure, 199,201 and an increase in referrals to a diabetic clinic when tighter targets for blood sugar control were introduced into the QOF.…”

Section: Scoping Review (Main Study)mentioning

confidence: 99%

“…[199][200][201]203 This pay-for-performance scheme did not (initially) have any incentives related to outpatient referrals but did provide incentives for chronic disease management that could have impacted on referrals. The evidence is clear that it did, with a step increase in referrals to renal clinics after the introduction of an incentive to identify and manage patients with renal failure, 199,201 and an increase in referrals to a diabetic clinic when tighter targets for blood sugar control were introduced into the QOF. 203 Referrals also increased to neurology clinics following an incentive to provide better seizure control for patients with epilepsy, 200 although in this study a neurologist provided additional educational support to practices at the same time.…”

Section: Scoping Review (Main Study)mentioning

confidence: 99%

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Outpatient services and primary care: scoping review, substudies and international comparisons

Winpenny

Miani

Pitchforth

et al. 2016

Health Serv Deliv Res

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AimThis study updates a previous scoping review published by the National Institute for Health Research (NIHR) in 2006 (Roland M, McDonald R, Sibbald B.Outpatient Services and Primary Care: A Scoping Review of Research Into Strategies For Improving Outpatient Effectiveness and Efficiency. Southampton: NIHR Trials and Studies Coordinating Centre; 2006) and focuses on strategies to improve the effectiveness and efficiency of outpatient services.Findings from the scoping reviewEvidence from the scoping review suggests that, with appropriate safeguards, training and support, substantial parts of care given in outpatient clinics can be transferred to primary care. This includes additional evidence since our 2006 review which supports general practitioner (GP) follow-up as an alternative to outpatient follow-up appointments, primary medical care of chronic conditions and minor surgery in primary care. Relocating specialists to primary care settings is popular with patients, and increased joint working between specialists and GPs, as suggested in the NHS Five Year Forward View, can be of substantial educational value. However, for these approaches there is very limited information on cost-effectiveness; we do not know whether they increase or reduce overall demand and whether the new models cost more or less than traditional approaches. One promising development is the increasing use of e-mail between GPs and specialists, with some studies suggesting that better communication (including the transmission of results and images) could substantially reduce the need for some referrals.Findings from the substudiesBecause of the limited literature on some areas, we conducted a number of substudies in England. The first was of referral management centres, which have been established to triage and, potentially, divert referrals away from hospitals. These centres encounter practical and administrative challenges and have difficulty getting buy-in from local clinicians. Their effectiveness is uncertain, as is the effect of schemes which provide systematic review of referrals within GP practices. However, the latter appear to have more positive educational value, as shown in our second substudy. We also studied consultants who held contracts with community-based organisations rather than with hospital trusts. Although these posts offer opportunities in terms of breaking down artificial and unhelpful primary–secondary care barriers, they may be constrained by their idiosyncratic nature, a lack of clarity around roles, challenges to professional identity and a lack of opportunities for professional development. Finally, we examined the work done by other countries to reform activity at the primary–secondary care interface. Common approaches included the use of financial mechanisms and incentives, the transfer of work to primary care, the relocation of specialists and the use of guidelines and protocols. With the possible exception of financial incentives, the lack of robust evidence on the effect of these approaches and the contexts in which they were introduced limits the lessons that can be drawn for the English NHS.ConclusionsFor many conditions, high-quality care in the community can be provided and is popular with patients. There is little conclusive evidence on the cost-effectiveness of the provision of more care in the community. In developing new models of care for the NHS, it should not be assumed that community-based care will be cheaper than conventional hospital-based care. Possible reasons care in the community may be more expensive include supply-induced demand and addressing unmet need through new forms of care and through loss of efficiency gained from concentrating services in hospitals. Evidence from this study suggests that further shifts of care into the community can be justified only if (a) high value is given to patient convenience in relation to NHS costs or (b) community care can be provided in a way that reduces overall health-care costs. However, reconfigurations of services are often introduced without adequate evaluation and it is important that new NHS initiatives should collect data to show whether or not they have added value, and improved quality and patient and staff experience.FundingThe NIHR Health Services and Delivery Research programme.

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Section: Scoping Review (Main Study)mentioning

confidence: 99%

Section: Scoping Review (Main Study)mentioning

confidence: 99%

Outpatient services and primary care: scoping review, substudies and international comparisons

Winpenny

Miani

Pitchforth

et al. 2016

Health Serv Deliv Res

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“…1,3,4 At present, there is evidence that a large proportion of people with CKD are undiagnosed and that management is suboptimal, with evidence to suggest that practitioners do not currently readily accept national guidelines. [5][6][7] A range of concerns have been raised by GPs, including difficulties associated with: assigning a diagnosis; the stigmatising effect of a diagnosis; explaining the concept of CKD to patients; achieving blood pressure targets; complicated medication regimens; and uncertainty about referral to secondary care. 8 The introduction of guidelines for the management of CKD requires a considerable change in behaviour by primary care clinicians.…”

Section: Introductionmentioning

confidence: 99%

Understanding the management of early-stage chronic kidney disease in primary care: a qualitative study

Blakeman¹,

Protheroe²,

Chew‐Graham³

et al. 2012

Br J Gen Pract

114

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“…Reports have shown an increase of 3-6 years in the mean age of the referral population to nephrologists post-eGFR reporting. 1,23,24 Concurrently, there have been increases of 6%-25% in women detected and referred to nephrology care with eGFR reporting. 2,23 With advanced CKD, ongoing sarcopenia, malnutrition, and higher comorbidity have led to this same population being initiated on dialysis at higher levels of eGFR.…”

Section: Discussionmentioning

confidence: 99%

The Association of eGFR Reporting with the Timing of Dialysis Initiation

Sood

Komenda

Rigatto

et al. 2014

Journal of the American Society of Nephrology

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Automated reporting of eGFR by laboratories has been widely implemented during the last decade. Over this same period, a steady increase in eGFR at dialysis initiation has been reported. This study examined trends in eGFR at dialysis initiation over time among incident dialysis patient populations before and after eGFR reporting. All patients who initiated dialysis between January of 2001 and December of 2010 in four Canadian provinces that implemented province-wide automated eGFR reporting and had an eGFR measure at dialysis initiation were included in the study (n=22,208). The primary outcome was change over time in eGFR among patients at dialysis initiation. An interrupted time series and adjusted multilevel regression models were used to determine the differences in eGFR at dialysis initiation before and after reporting. We observed a linear increase in the mean eGFR at dialysis initiation from 9.1 to 10.8 ml/min per m 2 during the study period. There was no change in the trajectory of the eGFR at dialysis initiation before or after eGFR reporting in crude or adjusted models accounting for case mix and facility characteristics. These findings were consistent among age and sex strata and when the proportions of patients with an eGFR$10.5 or $12 ml/min per m 2 were examined. In conclusion, automated laboratory-based eGFR reporting did not influence eGFR at dialysis initiation among incident dialysis patient populations. Concerns that widespread eGFR reporting leads to earlier dialysis initiation are not supported by this study.

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Renal quality outcomes framework and eGFR: impact on secondary care

Cited by 18 publications

References 25 publications

Outpatient services and primary care: scoping review, substudies and international comparisons

Outpatient services and primary care: scoping review, substudies and international comparisons

Understanding the management of early-stage chronic kidney disease in primary care: a qualitative study

The Association of eGFR Reporting with the Timing of Dialysis Initiation

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