The increasing incidence and prevalence of CKD, the growing demands on healthcare providers, and the increasing complexity of patients with CKD are factors that remind us it takes a healthcare team to care for patients with kidney disease. Primary care physicians (PCPs) are an integral part of the team, but the lack of streamlined communication and coordination between PCPs and nephrologists pose a challenge. In a recent quality improvement initiative published in AJKD, researchers evaluated the utility of specifically tailored tools on improving awareness and identification of CKD among PCPs, as well as co-management between PCPs and nephrologists. Dr. William Haley (WH), lead author of the article, discusses this topic with Dr. Abdo Asmar (eAJKD), eAJKD Advisory Board member.
eAJKD: What inspired the idea of the study?
WH: We previously reported that advanced CKD care among nephrologists and non-nephrologists was suboptimal. Whereas co-management with nephrologists has been widely accepted as both desirable and necessary, about half of the patients with CKD stage 4 were treated solely by non-nephrologists, and CKD care in this group was particularly poor. Meanwhile, patients with risk factors for CKD (diabetes, hypertension, advanced age, CVD) are highly prevalent in PCP practices, begging the question about CKD awareness. A blue-ribbon Stakeholders Consensus Panel of leaders in nephrology and primary care, non-nephrology specialists, midlevel providers, and methodology experts was convened to address this situation and assist PCPs in their efforts to better identify, treat, and manage CKD patients.
eAJKD: Can you please summarize the major findings of your study?
WH: PCPs improved processes for CKD identification, referral to nephrologists, communication, and execution of co-management plans. Nephrologists improved referral and co-management processes. Pre-intervention, nephrologists noted that patients generally did not know the reason for referral and test duplication was common; they asserted the need for better awareness of CKD and earlier referral. There was not a co-management process in place in most of the PCP or nephrology practices. Post-intervention, PCP interviews documented increased awareness of risk factors, the need to track high-risk patients, and the importance of early referral. Furthermore, nephrologist recognized heightened attention to communication and co-management with PCPs, and increased levels of satisfaction among all parties.
eAJKD: Can you briefly explain the role of qualitative research in improving health care delivery? What do you believe are some of the advantages, limitations, and challenges?
WH: We have noted failures to impact CKD practice and outcomes, despite a decade since the publication of guidelines. As we pointed out in our methodology paper, medical care is embedded in a complex system that exists in a dynamic equilibrium, and significant changes from that equilibrium require more than a little jiggering. Therefore a multi-faceted approach is required, and, moreover, one that aims to achieve goals of care by studying and improving processes of healthcare delivery. Additionally, in the present work, we pointed out that co-management hinges on effective communication, and noted that lack of communication and coordination among PCPs and nephrologists has been cited as a major systemic barrier to improving CKD outcomes (Parker et al; Rettig et al). Berwick, a renowned expert in healthcare improvement, has argued that the traditional quantitative evidence paradigm is inadequate in quality improvement trials. Rather, he favors Pawson and Tilley’s construct: context plus mechanisms equals outcomes, wherein the success of a program relates to the introduction of appropriate ideas and opportunities. The latter contrasts with the classic rules of inference, which, importantly, favor the status quo. Thus, changes in care processes are best measured with qualitative methods, which are better suited to providing essential information about such mechanisms and contexts. Qualitative research criteria include credibility, transferability, reliability, and confirmability. In our study, qualitative methods used by our team that yielded key themes (Box 1) required active participation of a qualitative expert to support these criteria.
eAJKD: Can you please describe the specific CKD tools used in this study, and they can be practically adopted in clinical practice?
WH: This critical step assured that we were providing tools to PCPs that were likely to work best in the non-nephrology setting to improve processes. The 7 tools implemented in this project were designed to address these concerns; each is described in Table 1 in terms of function, intended user, intent of fool, format of tool, and notes on use. The lack of knowledge about appropriate timing of referrals was addressed with the development of the “CKD Screening Protocol/When to Refer” tool. Communication tools included the “Post-Consult Letter” tool, which served as a reminder of clinical issues to address in CKD and facilitated explicit communication of a co-management plan. The engagement and enthusiasm of the site champions and physician leaders in each practice were critical to successful tool implementation and changes in practice, however, the perceived burden of such efforts was found to be light with both nephrologists and PCPs giving very favorable satisfaction rankings.
eAJKD: What are some practical take home messages for PCPs and nephrologists?
WH: Our tasks, as outlined by the Stakeholders Consensus Panel, were to improve CKD identification and appropriate referral to nephrologists, improve communication, and advance co-management among PCPs and nephrologists, while minimizing the time investment required. We found that the use of specifically tailored tools developed using Facilitated Process Improvement methodology led to enhanced awareness and identification of CKD among PCPs, increased communication between practices, and improvement in co-management and cooperation between PCPs and nephrologists. We believe that a similar assessment of practice patterns by nephrologists and their referring PCP practices, together with the use of proven tools, will result in enhanced identification and referral of patients with CKD, improvement in communication, and satisfaction on the part of all parties.