Patient and provider experience and perspectives of a risk-based approach to multidisciplinary chronic kidney disease care: a mixed methods study

Abstract

Background The Kidney Failure Risk Equation (KFRE) predicts risk of progression to kidney failure and is used to guide clinical decisions for patients with chronic kidney disease (CKD). Methods The KFRE was implemented to guide access to multidisciplinary care for CKD patients in Alberta, Canada, based on their 2-year risk of kidney failure. We used a mixed methods approach to investigate patients’ and providers’ perspectives and experiences 1 year following KFRE implementation. We conducted post-implementation interviews with multidisciplinary clinic providers and with low-risk patients who transitioned from multidisciplinary to general nephrology care. We also administered pre- and post-implementation patient care experience surveys, targeting both low-risk patients discharged to general nephrology and high-risk patients who remained in the multidisciplinary clinic, and provider job satisfaction surveys. Results Twenty-seven interviews were conducted (9 patients, 1 family member, 17 providers). Five categories were identified among patients and providers: targeted care; access to resources outside the multidisciplinary clinics; self-efficacy; patient reassurance and reduced stress; and transition process for low-risk patients Two additional categories were identified among providers only: anticipated concerns and job satisfaction. Patients and providers reported that the risk-based approach allowed the clinic to target care to those most likely to experience kidney failure and most likely to benefit from multidisciplinary care. While some participants indicated the risk-based model enhanced the sustainability of the clinics, others expressed concern that care for low-risk patients discharged from multidisciplinary care, or those now considered ineligible, may be inadequate. Overall, 413 patients completed the care experience survey and 73 providers completed the workplace satisfaction survey. The majority of patients were satisfied with their care in both periods with no overall differences. When considering the responses “Always” and “Often” together versus not, there were statistically significant improvements in domains of access to care, caring staff, and safety of care. There were no differences in healthcare providers’ job satisfaction following KFRE implementation. Conclusions Patients and healthcare providers reported that the risk-based approach improved the focus of the multidisciplinary CKD clinics by targeting patients at highest risk, with survey results suggesting no difference in patient care experience or healthcare provider job satisfaction. Electronic supplementary material The online version of this article (10.1186/s12882-019-1269-2) contains supplementary material, which is available to authorized users.

A validation study of the kidney failure risk equation in advanced chronic kidney disease according to disease aetiology with evaluation of discrimination, calibration and clinical utility

“…Indeed, a proposed KFRE cut-off of ≥10% at 2-years has been reported to select patients into multidisciplinary advanced care clinics, a strategy that has captured high-risk patients with an eGFR> 30 ml/min/1.73m 2 . This approach has provided significant cost-savings through the reallocation of resources to those most likely to progress to ESRD [ 6 ] and was valued to be of benefit from a qualitative analysis of clinicians and patients’ perspectives [ 23 ]. Further prospective work with quality improvement initiatives or cluster randomised trials would be helpful to gauge how successful the KFRE is at achieving higher rates of pre-emptive transplantation or mature AV fistula formation in those who progress to ESRD.…”

Chronic Kidney Disease Testing Among Primary Care Patients With Type 2 Diabetes Across 24 U.S. Health Care Organizations

“…Glucagonlike peptide 1 receptor agonists (GLP-1 RA) are also noted to reduce kidney disease end points, primarily albuminuria, progression of albuminuria, and cardiovascular events in people with CKD (10)(11)(12)(13). CKD status also helps determine evidence-based recommendations for interdisciplinary care (dietitian, pharmacist, and nephrologist) (9,10,(14)(15)(16).…”

Your Path to Transplant: A randomized controlled trial of a tailored expert system intervention to increase knowledge, attitudes, and pursuit of kidney transplant

“…At the patient and family level, discussions between participants and social workers, 36 web‐based education, 33,42 home‐based educational meetings with patients, 43 and meetings using technology to seek donors, 44 and involving a patient's social network, including potential living donors 45 have proven effectiveness. At the provider and system level, research has found that transplant facilities with specifically tailored toolkits to coordinate patient care, 46,47 and risk‐based approaches identifying patients in need of targeted care 48,49 were more successful. Interventions including multiple levels of the socioecological model may be needed, perhaps in combination 50‐52 …”