Table 3 Overall Impact of eGFR Automatic Reporting: Benefits and Challenges (n = 19)

Time Savings

I thought it was great [to have it automatically reported], because I didn’t have to try to manually calculate it. Prior I had been using kind of just ballpark numbers to try to guesstimate when I thought somebody’s renal function was starting to decline and if I needed to adjust medication. So, it was challenging because it added work to my day to have to manually do that or try to assess that… So it has made life easier for me to have it calculated. – FM PCP

· automatic calculation and reporting makes approach and work to CKD management more streamlined

· easier to have eGFR calculated for provider - saves valuable clinic time to not calculate equation on own when they need it

I think it’s a good tool. So the fewer steps that we have to do to get to the right answer, and the right thing to do, the better it is. I think the automatic calculator is quicker and better at math than I am, and more reliable. And so, it takes away some of the potential for error that I might have introduced by manually doing the calculations myself. – IM PCP

Grateful for the Information

Well, what it did was show that there were a lot of people with worse renal function than we had appreciated previously based just on creatinine. … we started looking at treatment of Stage 3′s, …trying to put [them] on ACE inhibitors. It wasn’t a usual practice until that [automatic reporting] happened. And without [automatic reporting], it would be very difficult to do. – IM PCP

· providers wish they had the automatic eGFR value prior

· providers feel the missed opportunity to help some patients by not having the automatic value previously

· believe it to be a good clinical tool

The ongoing reaction I’ve had [to the automatic reporting], is wishing I had known this a longtime ago. … It just makes me think of all the stuff I wasn’t doing or keeping track of before. - FM NP

· helpful to have a more precise picture of renal health and CKD staging than just creatinine could provide

I find it is really helpful. I think it’s a useful tool to use as a screen. And I really think it’s an important item to have on the problem list so that you pay attention when you’re prescribing… it becomes part of your decision making if you’re going to moderate dosing of medication. – IM PCP

Increased Awareness

It helps me when I review the charts for certain treatments or just to get to know the patient. It makes me aware that I can’t order certain medications. And it definitely makes me aware that I should check it at regular intervals to make sure I don’t miss when it starts trending down. – IM PCP

· created more awareness of and attention to tracking CKD in general

· now know about and can manage all the patients provider did not know about before automatic reporting began that have a “normal or slightly abnormal” creatinine and an abnormal eGFR

Well, it’s made more awareness of chronic kidney disease. It’s sort of opened up a whole new [population] of chronic kidney disease patients. And it’s probably a more sensitive number to follow, rather than the creatinines…I can have a creatinine of 1.4 in one person, with a normal GFR, and a creatinine of .9 with an abnormal GFR - the GFR is simpler to pull. So ultimately I like it better. - FM PCP

· identified a pool of patients on providers’ panel with CKD status much worse than the creatinine value alone was indicating – would not have “known” about these patients or referred on to Nephrology without automatic reporting

Some of the patients who had a mildly abnormal creatinine I’m now finding have a much more reduced GFR, and that puts them in a higher stage of chronic kidney disease. And I am picking up a few of those that I wouldn’t have known before and then referring them on…It’s just that it alerts me to the fact that their kidney disease is worse than I might have suspected just from the level of creatinine. – IM PCP

Improve Patient Care and Management

It’s very much helped with the care of patients. I feel like I know what’s going on all the time now and I do a better job…I feel like all the people I didn’t, you know, do right by before - and that kind of kills me - I feel like I give them good care finally. –FM NP

· overall provide better patient care by having the automatic eGFR value

· improves the ability of providers to assess and act on a patient’s renal health and functioning earlier or to determine appropriate referral to Nephrology at earlier time points

If there’s a low GFR but their creatinine is normal, I might have ignored that before…[because] I thought [their renal function] was normal. So that’s the major difference …because before if the creatinine was one, I might not have ordered it for another year. Whereas now, if it reflects a low GFR I might order it more often, or start adjusting the medicines. So I’m definitely ordering more tests. - FM PCP

· greatly helps in medication management efforts, including determining both the appropriate type and dosage of medication

· having the more sensitive value of the eGFR, along with creatinine, helps give gradation and refinement to patients’ renal health – helps provider determine “just how bad” a patient may or may not be

And the one thing that I feel it does do, if a patient goes into a hospital, having GFR value [CKD stage] on the problem list will protect him from somebody starting a dangerous medication and monitor it more closely… I want to optimize the person’s blood pressure. I want to optimize their sugar control. I want to be careful with what medications I’m using… monitoring them with the GFR has more meaning than monitoring them with the creatinine. So it’s nice to have it more available now. - IM PCP

· helps provider manage the Medicare refresh diagnosis process related to CKD status

Challenges

Common Theme and Key Findings

Illustrative Quotes

Patient Confusion / Fear

Some patients were shocked – they were dismayed. They wanted to talk to me. I had some people who just couldn’t understand, asking ‘What’s wrong with my kidneys?’… FM NP

· initially caused some otherwise healthy patients concern and upset regarding “suddenly” having a CKD diagnosis

So, I think it caused distress and some fear because I never told them anything was wrong before, or I was waiting until their creatinine got high before I figured it out. - FM PCP

· initially caused some otherwise healthy patients undue fear and stress regarding their kidney health and future possibility of dialysis

It’s still a bit of an issue where there is that disconnect between some of the older patients who have a normal creatinine but their GFR is in the chronic kidney disease range. So it generated for some patients’ questions, concern, alarm that I think wasn’t really necessary. – IM PCP

Increase Provider Workload

So basically, there might have been fifty or a hundred people who I had considered normal, who all of a sudden had CKD3, by the GFR definition. So really, it’s more work, but if that’s the definition, then that’s the definition, and it’s real. So I’ve made mechanisms to deal with it. – FM PCP

· initial reporting created a “new”, “unknown”, and “larger” pool of patients in Stage 3 that now needed outreach and follow-up

· initially created a “thinking” burden when trying to determine the correct e GFR value on lab report – (both African American and Caucasian values reported)

I think the automatic reporting is an absolutely great idea. But, the actuality is we’ve got some problems with how the computer reports it…I should not have to read every time the African and non-African American values when the computer could somehow designate that. If we have race in our computer, it should be automatically reported as the [correct] GFR and the computer should be estimating for the race. I shouldn’t have to be wasting one second of time thinking about that…It hasn’t created clinical harm, but it’s just extra thought and extra work for me. – IM PCP

· generated more follow up and tracking work for providers – another condition to now follow and manage

· extra time and workload for provider to create their own systems and processes for tracking, monitoring, and following up on patients eGFR values and renal health

Initially I felt there was a little confusion to patients around giving the limits of normal GFR, so that the patient who was older could have a normal creatinine but an abnormal GFR, and the lab result would indicate chronic kidney disease. And it just added a little extra problem of something you either had to explain to the patient, or that they would ask questions about…I would usually then end up having to generate some sort of a letter explaining it, rather than just sending out a copy of the lab report, which made more work for me. – IM PCP

· extra time and workload for provider to address patient fears and concerns regarding meaning of eGFR value and CKD stage/status (phone calls, creating patient letters)