When laboratories report estimated glomerular filtration rates in addition to serum creatinines, nephrology consults increase

Jain, Arsh K.; McLeod, Ian K.; Huo, Cindy Yan; Cuerden, Meaghan; Akbari, Ayub; Tonelli, Marcello; Walraven, Carl van; Quinn, Rob; Hemmelgarn, Brenda R.; Oliver, Matt J.; Li, Ping; Garg, Amit X.

doi:10.1038/ki.2009.158

Cited by 88 publications

(67 citation statements)

References 39 publications

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“…Although overall (unadjusted) CKD recognition improved to 54% among patients with eGFR 10-29 ml/min per 1.73 m 2 , only 2% of all patients with CKD saw a nephrologist in the 12 months after VA laboratories implemented automated eGFR reporting. Our results contrast with notable increases in nephrology referrals that occurred after eGFR reporting in several vertically integrated health care settings in Canada (10,11,16), the United Kingdom (17), and Australia (12). Several factors may explain these differences.…”

Section: Discussioncontrasting

confidence: 55%

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Recognition of CKD After the Introduction of Automated Reporting of Estimated GFR in the Veterans Health Administration

Wang

Maciejewski

Hammill

et al. 2014

Clinical Journal of the American Society of Nephrology

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SummaryBackground and objectives Early detection of CKD is important for slowing progression to renal failure and preventing cardiovascular events. Automated laboratory reporting of estimated GFR (eGFR) has been introduced in many health systems to improve CKD recognition, but its effect in large, United States-based health systems remains unclear.Design, setting, participants, & measurements Using Veterans Affairs (VA) laboratory and administrative data, two nonoverlapping national cohorts of patients receiving care in VA medical centers before (n=66,323) and after (n=16,670) implementation of automated eGFR reporting between 2004 and 2010 were identified. Recognition was assessed by the presence of new CKD diagnostic codes, use of additional diagnostic testing, outpatient nephrology visits, or overall CKD recognition (receipt of at least one of these outcomes) for each patient during the 12-month period after their first eligible creatinine or eGFR laboratory result. Generalized estimating equations were used to assess change before and after automated eGFR reporting.Results Overall CKD recognition increased from 22.1% of veterans before eGFR reporting to 27.5% in the posteGFR reporting period (odds ratio [OR], 1.19; 95% CI, 1.12 to 1.27; P,0.001). Higher overall CKD recognition was driven largely by increased documentation of CKD diagnosis codes in medical records (OR, 1.31; 95% CI, 1.21 to 1.41; P,0.001) and diagnostic testing for CKD (OR, 1.13; 95% CI, 1.03 to 1.24; P,0.01) rather than outpatient nephrology consultation. Automated eGFR reporting was not associated with greater CKD recognition among black or older patients (P=0.07).Conclusions Automated eGFR laboratory reporting improved documentation of CKD diagnoses but had no effect on nephrology consultation. These findings suggest that to advance CKD care, further strategies are needed to ensure appropriate follow-up evaluation to confirm and effectively evaluate CKD.

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Section: Discussioncontrasting

confidence: 55%

“…With the exception of a large Canadian study that did not find a significant change in laboratory testing with serum creatinine (11), few studies have evaluated the effect of eGFR reporting on follow-up tests for CKD. The significant effect of eGFR reporting on diagnostic testing was largely driven by the use of urine microalbumin testing.…”

Section: Discussionmentioning

confidence: 99%

Recognition of CKD After the Introduction of Automated Reporting of Estimated GFR in the Veterans Health Administration

Wang

Maciejewski

Hammill

et al. 2014

Clinical Journal of the American Society of Nephrology

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“…Several studies tried to evaluate the impact of reporting eGFR in the practice of primary care and the rate of referral for nephrology evaluation. In two reports from Jain et al 5 and Hemmelgarn et al, 6 respectively, it was found that (1) reporting eGFR leads to an increase in nephrology consultation by an average of 24% and (2) the rate of first outpatient nephrology visit for stage 3 CKD patients or worse is increased by 17.5 times. These changes were predominantly observed in elderly women and those with hypertension, diabetes, and comorbidity.…”

Section: Discussionmentioning

confidence: 99%

The Impact of Reporting Estimated Glomerular Filtration Rate

et al. 2011

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The 'Kidney Disease Outcomes Quality Initiative' guidelines recommend laboratory reporting of a calculated estimated glomerular filtration rate (eGFR). The United Kingdom and several states already mandate reporting eGFR for every laboratory serum creatinine (sCr) measurement. In our study, we evaluated the impact of reporting eGFR on the management of hospitalized patients. We reviewed the medical records for 2000 patients, 1000 pre-and 1000 post-reporting eGFR. We excluded patients with previous diagnosis of chronic kidney disease, acute kidney failure, and end-stage renal disease. We analyzed the subgroup of patients with eGFR <60 and sCr <1.5 mg/dL. We did not notice an increase in the number of renal consult, ordering laboratory or imaging study to evaluate chronic kidney disease. The prescription habits did not change for nephrotoxic medications (nonsteroidal anti-inflammatory drugs and aminoglycosides). We did not find any change in the percentage of patients who received hydration for a radiological contrast study or the use of N-acetylcysteine. In conclusion, reporting eGFR did not improve the renal management of hospitalized patients.

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“…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. In a United States dialysis cohort study of greater than 800,000 patients, the mean age of patients starting dialysis with an eGFR.15 ml/min per m 2 was 68.4 versus 59.3 years in those patients started with an eGFR,5 ml/min per m 2 .…”

Section: Discussionmentioning

confidence: 99%

“…[1][2][3][4] There remains, however, limited knowledge regarding the impact of this public health intervention on patient outcomes and health care resource use. Several studies have shown that, although routine eGFR reporting seems to result in an increase in appropriate referral for specialist care and medication prescription, it may also increase the number of unnecessary referrals and the number of patients inappropriately labeled with a chronic disease.…”

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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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When laboratories report estimated glomerular filtration rates in addition to serum creatinines, nephrology consults increase

Cited by 88 publications

References 39 publications

Recognition of CKD After the Introduction of Automated Reporting of Estimated GFR in the Veterans Health Administration

Recognition of CKD After the Introduction of Automated Reporting of Estimated GFR in the Veterans Health Administration

The Impact of Reporting Estimated Glomerular Filtration Rate

The Association of eGFR Reporting with the Timing of Dialysis Initiation

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