Perceived Benefits and Challenges of a Risk-Based Approach to Multidisciplinary Chronic Kidney Disease Care: A Qualitative Descriptive Study

Abstract

Background:The kidney failure risk equation (KFRE) provides an estimate of risk of progression to kidney failure, and may guide clinical care.Objective:We aimed to describe patient, family, and health care provider’s perspectives of the perceived benefits and challenges of using a risk-based approach to guide care delivery for patients with advanced chronic kidney disease (CKD), and refine implementation based on their input.Methods:We used qualitative methodology to explore perceived benefits and challenges of implementing a risk-based approach (using the KFRE) to determine eligibility for multidisciplinary CKD care in Southern Alberta. We obtained perspectives from patients and families through focus groups, as well as input from health care providers through interviews and open-ended responses from an online survey. Twelve patients/family members participated in 2 focus groups, 16 health care providers participated in an interview, and 40 health care providers responded to the survey.Results:Overall, participants felt that a KFRE-based approach had the potential to improve efficiency of the clinics by targeting care to patients at highest risk of kidney failure; however, they also expressed concerns about the impact of loss of services for lower risk individuals. Participants also articulated concerns about a perceived lack of capacity for adequate CKD patient care in the community. Our implementation strategy was modified as a result of participants’ feedback.Conclusions:We identified benefits and challenges to implementation of a risk-based approach to guide care of patients with advanced CKD. Based on these results, our implementation strategy has been modified by removing the category of referral back to primary care alone, and instead having that decision made jointly by nephrologists and patients among low-risk patients.

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

“…Similar to our pre-implementation study [13], the primary concern identified by healthcare providers regarding use of the KFRE to risk stratify patients for multidisciplinary care was potential for patients with lower risk of kidney failure experiencing more rapid progression over time without multidisciplinary care. These provider concerns may stem from poor perceptions of patient self-efficacy and primary care in general and is consistent with other studies [26–31].…”

“…Our pre-implementation findings [13] revealed both patient and provider concerns relating to care experience and quality for lower risk patients who would be risk-stratified out of the multidisciplinary clinic, or considered ineligible, following KFRE implementation. Consequently, our study focuses on the perspectives and experiences of low-risk multidisciplinary clinic patients who were discharged from multidisciplinary care following KFRE implementation and explores satisfaction of these low-risk patients as well as satisfaction of higher-risk patients who remain in, or were referred to, the multidisciplinary clinic during the study timeframe.…”

“…Text data was imported into NVivo Version 12 software to facilitate data analysis (QSR International Ltd., Doncaster, Australia). Based on findings from the pre-implementation qualitative study [13], we applied a directed content analysis [17] approach to focus the interview guides, identify relationships between the pre- and post-implementation code definitions and to qualitatively describe [18] participant perspectives; we did not apply a theory to guide analysis. We also asked open-ended questions to identify new content categories and extend our conceptual framework relating to the benefits and challenges of a risk-based approach to multidisciplinary CKD care [17].…”

“…The KFRE provides the opportunity to identify patients at higher risk of progression, and tailor their care accordingly. We previously reported a qualitative description of patients’, family members’, and providers’ perceptions of the KFRE [13], which informed our implementation strategy. This follow-up study provides a description of patients’ and providers’ experiences and perceptions 1 year following KFRE implementation, as well as assessments of patient care experience and provider job satisfaction before and 1 year after implementation.…”

The Kidney Failure Risk Equation for Prediction of Allograft Loss in Kidney Transplant Recipients

“…These variables are routinely collected in CKD care, enabling integration of the KFRE into electronic health records and facilitating its application for risk-based clinical decision making, such as for triage of nephrology referrals and dialysis access planning. 7 , 8 , 9 , 10 …”