Improving care coordination between nephrology and primary care

Abstract

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.