Follow-up of Abnormal Estimated GFR Results Within a Large Integrated Health Care Delivery System: A Mixed-Methods Study

Abstract

Background: Timely follow-up of abnormal laboratory results is important for high-quality care. We sought to identify risk factors, facilitators, and barriers to timely follow-up of an abnormal estimated glomerular filtration rate (eGFR) for the diagnosis of chronic kidney disease. Study Design: Mixed-methods study: retrospective electronic health record (EHR) analyses, physician interviews. Setting & Participants: Large integrated health care delivery system. Quantitative analyses included 244,540 patients 21 years or older with incident abnormal eGFRs from January 1, 2010, to December 31, 2015, ordered by 7,164 providers. Qualitative analyses included 15 physician interviews. Exposures: Patient-, physician-, and system-level factors. Outcome: Timely follow-up of incident abnormal eGFRs, defined as repeat eGFR obtained within 60 to 150 days, follow-up testing before 60 days that indicated normal kidney function, or diagnosis before 60 days of chronic kidney disease or kidney cancer. Analytical Approach: Multivariable robust Poisson regression models accounting for clustering within provider were used to estimate risk ratios (RRs) and 95% CIs for lack of timely follow-up. Team coding was used to identify themes from physician interviews. Results: 58% of patients lacked timely follow-up of their incident abnormal eGFRs (ie, had a care gap). An abnormal creatinine result flag in the EHR was associated with better follow-up (RR for care gap, 0.65; 95% CI, 0.64-0.66). Patient online portal use and physician panel size were weakly associated with follow-up. Patients seen by providers behind on managing their EHR message box were at higher risk for care gaps. Physician interviews identified system-level (eg, panel size and assistance in managing laboratory results) and provider-level (eg, proficiency using EHR tools) factors that influence laboratory result management. Limitations: Unable to capture intentional delays in follow-up testing. Conclusions: Timely follow-up of abnormal results remains challenging in an EHR-based integrated health care delivery system. Strategies improving provider EHR message box management and leveraging health information technology (eg, flagging abnormal eGFR results), making organizational/staffing changes (eg, increasing the role of nurses in managing laboratory results), and boosting patient engagement through better patient portals may improve test follow-up. Complete author and article information provided before references.

Barriers and enablers to detection and management of chronic kidney disease in primary healthcare: a systematic review

“…Of the 20 included studies, 12 were interviews [7,10,[22][23][24][25][26][27][28][29][30][31], six were focus groups [5,6,8,[32][33][34][35][36], and two were surveys with open-ended responses [9,37] (Table 1). General practitioners, nurses, practice managers, pharmacists and medical assistants were represented across the 20 studies.…”

“…The most commonly reported barriers related to detection and management of CKD in primary care were categorised into the 'Environmental context and resources' domain and were reported in 16 studies [5,6,8,9,22,24,[26][27][28][29][30][31][32][33][34][35][36][37]. PC-Ps frequently perceived they lacked time to devote to this task [6,8,9,22,[26][27][28][29][30][31][32][33][34][35] and this was exacerbated by the limited amount of time available for patient appointments. The complex nature of managing multiple co-morbidities also meant additional time was needed for these patients.…”

“…A lack of educational resources for patients [8,33,34,37] was reported, although minimal detail was provided on the type of resources (for example brochures, online materials) that were desired. In addition, technological issues such as software not automatically flagging abnormal results [24,28,29]; and a lack of renumeration for tasks such as CKD screening within health system rebates [9,22] were reported. Attempts to implement changes in the primary care setting were obstructed by variations in practice operations [22], as well as a lack of CKDspecific information in insurance reports and other performance data [28].…”

“…There was also a reported perception that declining kidney function was an expected part of aging [6,7,32,35], and therefore it was more important to focus on overall quality of life rather than CKD. An additional barrier identified within this domain was the perceived cost to patients of managing CKDs [8,29,34], particularly the time and financial burden associated with attending multiple appointments and multiple blood tests. One study also reported that the current approach to healthcare was too reactive [5,36], and did not prioritise preventative measures that might minimise the risk of developing CKD, such as weight management.…”

“…It was also identified that there was a perception that there is inadequate training or education for PC-P on the management of CKD [8-10, 27, 28, 32, 34, 35, 37], resulting in some practitioners feeling unprepared to diagnose or manage patients with CKD. Other studies reported that practitioners were unfamiliar with management guidelines for CKD [8,28,29,32,34] (categorised into the theme 'lack of awareness of guidelines'), as well as available resources or support services, for example for conservative care [27,37]. Finally, there was a perception that the definition of CKD was not clear and resulted in diagnostic challenges [35].…”