Nephrology Referral Based on Laboratory Values, Kidney Failure Risk, or Both: A Study Using Veterans Affairs Health System Data

Duggal, Vishal; Montez‐Rath, Maria E.; Thomas, I‐Chun; Goldstein, Mary K.; Tamura, Manjula Kurella

doi:10.1053/j.ajkd.2021.06.028

Cited by 16 publications

(21 citation statements)

References 14 publications

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“…However, there is a well-documented underuse of ACR testing, which was also observed in our own study. 16,27 Electronic health record-embedded decision support systems that harness information on family history and preexisting conditions could alert…”

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

“… 13 A study 15 in Manitoba, Canada reported shortened wait times for nephrology referrals by triaging referral requests with a 3% 5-year KFRE risk cutoff and redirecting patients with risk below the cutoff to primary care management. Studies 16 , 17 in the UK and the US Veterans Affairs system have shown that referrals based on the KFRE risk compared with traditional criteria could result in substantial reallocation of which patients are being referred. Another UK study 10 , 18 found that combining a 5% 5-year KFRE risk cutoff with the National Institute for Health and Care Excellence referral guidelines would more effectively identify patients at high risk of progression to kidney failure while minimally altering referral volumes.…”

Section: Introductionmentioning

confidence: 99%

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Analysis of Specialty Nephrology Care Among Patients With Chronic Kidney Disease and High Risk of Disease Progression

et al. 2022

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IMPORTANCEIdentification of patients with chronic kidney disease (CKD) with high risk of progression to kidney failure can help ensure they receive appropriate and effective nephrology care. OBJECTIVE To examine whether patients with CKD at various levels of kidney failure risk receive nephrology care within 1 year of established risk. DESIGN, SETTING, AND PARTICIPANTS This population-based, retrospective cohort study collected nationwide administrative health claims data from 156 733 adult patients who met the Kidney Disease: Improving Global Outcomes initiative CKD diagnostic criteria between January 1, 2012, and December 31, 2019, and had an available urine albumin to creatinine ratio within 90 days of a serum creatinine laboratory test. Patients with a history of dialysis or kidney transplant, a prior visit with a nephrologist in the past year, or palliative care billing codes or those who died or disenrolled within 1 year of the albumin to creatinine ratio measurement were excluded. Data analysis was performed from September 10, 2022, to February 14, 2022.EXPOSURES Kidney failure risk computed with the 5-year Kidney Failure Risk Equation. MAIN OUTCOMES AND MEASURESThe main outcome was nephrology care rates across tiers of kidney failure risk, estimated as the proportion of individuals having a nephrologist visit within 1 year after index time. RESULTSThe study population consisted of 156 733 patients with CKD (mean [SD] age, 74.6 [8.4] years; 91 906 [58.6%] female; 86 457 [55.2%] White). A total of 106 004 patients (67.6%) had a low (Յ1%) 5-year risk of kidney failure. Nephrology visit rates increased with higher kidney failure risk.Among the 137 highest-risk patients, 79 (57.7%; 95% CI, 48.4%-64.7%) had a nephrology visit.Among 7730 patients with risk above a 10% threshold, 3208 (41.5%; 95% CI, 40.3%-42.4%) had a nephrology visit.CONCLUSIONS AND RELEVANCE This study's findings suggest that nearly half of patients with CKD at high risk of progressing to kidney failure do not have a nephrologist visit within 1 year of established risk. These findings have implications in the design of risk-based guidelines for referral and in the practice of delivering nephrology care to patients with CKD.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Analysis of Specialty Nephrology Care Among Patients With Chronic Kidney Disease and High Risk of Disease Progression

et al. 2022

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“…A recent retrospective study [ 25 ] compared referral volume based on the estimated risk of kidney failure and laboratory criteria. About 18% of CKD patients met laboratory indications for referral (eGFR <30 mL/min/1.73 m 2 ), where most were not truly referred in the following year and the median 2-year risk of kidney failure was 1.5%.…”

Section: Kfre For Referralmentioning

confidence: 99%

Risk-based versus GFR threshold criteria for nephrology referral in chronic kidney disease

Oliva-Dámaso

Delanaye

Oliva-Damaso

et al. 2022

Clinical Kidney Journal

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Chronic Kidney Disease (CKD) and kidney failure is a global health problem associated with morbidity, mortality and health care costs with unequal access to kidney replacement therapy between countries. The diversity of guidelines concerning referral from primary care to a specialist nephrologist determine different outcomes around the world among patients with CKD where several guidelines recommend referral when the glomerular filtration rate (GFR) is < 30 mL/min/1.73 m2 regardless of age. Additionally, fixed non-age-adapted diagnostic criteria for CKD that do not distinguish correctly between normal kidney senescence and true kidney disease can lead over-diagnosis of CKD in elderly and under-diagnosis of CKD in young patients and contributes to unfair referral of CKD patients to a kidney specialist. Non-age adapted recommendations contributes to unnecessary referral in very elderly with mild disease where risk of death consistently exceeds the risk of progression to kidney failure and on the other hand ignore the possibility of effective interventions of young patient with long life expectancy. The opportunity of mitigating CKD progression and cardiovascular complications in young patients with early stages of CKD is a task entrusted to primary care providers which are possibly unable to accomplish optimally guideline-directed medical therapy for this purpose. The shortage in the nephrology workforce has classically leaded to focus referral on advanced CKD stages preparing kidney replacement, but the need for hasty referral to at nephrologist because of urgent requirement for kidney replacement therapy in advanced CKD is still observed and changes are required to move towards reducing the kidney failure burden. Kidney Failure Risk Equation (KFRE) and its potential value is a novel tool that can guide wiser nephrology referrals and impact patient volumes.

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“…Among patients who met laboratory thresholds for nephrology referral, most did so based on an eGFR <30 mL/min/1.73 m 2 , and only 18% of these patients were referred. 9 These observations underscore the challenges in optimizing CKD care coordination. Health systems seeking to optimize CKD care delivery will need to assess their nephrology workforce and choose referral criteria that identify the highest-risk subset of patients.…”

mentioning

confidence: 99%

Too Many for Too Few: Finding Appropriate Nephrology Referrals for Patients With CKD That Optimize Outcomes

Chu

Lamprea‐Montealegre

Estrella

2022

American Journal of Kidney Diseases

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Nephrology Referral Based on Laboratory Values, Kidney Failure Risk, or Both: A Study Using Veterans Affairs Health System Data

Cited by 16 publications

References 14 publications

Analysis of Specialty Nephrology Care Among Patients With Chronic Kidney Disease and High Risk of Disease Progression

Analysis of Specialty Nephrology Care Among Patients With Chronic Kidney Disease and High Risk of Disease Progression

Risk-based versus GFR threshold criteria for nephrology referral in chronic kidney disease

Too Many for Too Few: Finding Appropriate Nephrology Referrals for Patients With CKD That Optimize Outcomes

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