Table 4 Comparison of Work Practices Related to CKD Management since Automatic eGFR Reporting (n = 19)

Patient Communication and Activation Activities

If it is under 60, I tell the patient about what’s going on. I spend time trying to educate the patient on that and things to avoid to stay as healthy as possible…I do talk to and counsel people more now than I ever have before, on the NSAID usage or abuse. And it may correlate in terms of timing with that [automatic reporting]. – IM PA

· increased counseling / education discussions with patients about GFR value, kidney health, and CKD management

6 (yes)

4 (yes)

10

7 (no)

2 (no)

9

I use the eGFR information quite a bit… have a conversation when people need more information about protecting their kidneys if they get down to a GFR below 60. So, if their cholesterol is high, give them information about their cholesterol. If their GFR is low, try to get them to do some things to protect their kidneys, etc. – FP PA

I am more aggressive about counseling for prevention of kidney disease, now… I start talking with them about making sure they’re getting plenty of water, avoiding caffeine, making sure their blood pressure is in control, making sure they’re not on high protein diets that are more challenging for the kidney to filter, etc. … and so just a lot of a more aggressive lifestyle counseling for things that may maintain or maybe even improve kidney function. – FP PCP

It depends on the patient and what I’m explaining, whether or not I go into it with them. Obviously, if they ask me, then I tell them. Generally I don’t bring it up – it’s more how I practice what I’m doing. – IM PA

· created specialized letters and phone talking points for explaining eGFR results and follow up activities to patients

9 (yes)

4 (yes)

13

I send the patient a letter, using a dot phrase which described the patient’s kidney function – explains that if it’s a little bit off, it could be for many reasons, and that often it is age and kidneys, but that at this point it’s not concerning and we want to re-check in 3 months. – FP NP

4 (no)

2 (no)

6

It does generate the need for additional information. I have dot phrases that I use to explain GFR, just to let them know the filtration rate and what that means. I have dot phrases that explain where they can get more information from the [National Kidney Foundation]– FP PCP

So I have devised my own method that seems rational to me…I have a dot phrase for when the creatinine is normal, and the GFR is low and it says, ‘Your creatinine is normal but your GFR is low, sometimes this can be due to diabetes or high blood pressure, and a lot of times in three months it changes back to normal, so let’s check it in 3 months…’ etc. – IM PCP

Overall Referral Patterns to Nephrology

Yes, I am possibly referring more [to Nephrology]…I would have to say about 5 percent more, and chart review is my first request. – IM PA

· subtle increase (approx. 1 to 2 month)

8

6

14

It’s probably a subtle increase, because the information is so clearly in your face, as a clinician you can just see it. It would be hard to ignore, or hard to get distracted and not pick it up, the way it’s reported. – NP IM

I think it has increased the number…probably once a month I’m referring someone - maybe once or twice a month - to the nephrologist…for a face to face or chart review, it varies. –FP PCP

It has some because… once it gets down towards thirty, then I’ll refer them to Nephrology to take a look at it. And sometimes if I’m really not sure and it’s getting closer and I’m worried about something or other, I’ll have the nephrologist do a chart review. – IM PCP

· no perceived increase in referrals

4

0

4

It’s not had much impact on my referral to nephrology because usually I don’t refer unless it gets much lower than that. So for the mildly decreased GFR’s of 45 to 60 range, I’m still managing it. – FP PCP

No, I don’t refer more… I just treat them. They only ones that get a chart review are the Stage Fours. And they’re not that many of those. – IM PCP

· believe referrals have decreased

1

0

1

I’ve probably cut down the number of referrals to Nephrology… I don’t know that I referred a lot before the change, but I would say in general probably it’s reduced the amount of referrals because I can monitor more, and try to help prevent them from progressing. I can do interventions earlier. – FP PCP

Typical GFR Referral “Cut-off” Values

Well, it’s probably when it gets down closer to 40 or below I’m more likely to do a referral to Nephrology and specify a chart review. …If it’s hovering around 60, or if it’s in the mid-fifties, I don’t feel so compelled to do anything about it, right then, except to make sure that the patient gets rechecked again in 6 months, or something. – IM NP

· eGFR value low 40’s to 40

1

4

5

I believe it’s 40 or 45, is the cutoff point between seeing the Nephrologist or not… if it’s in that 40 range or so, then usually I go ahead and refer at some point. Usually I follow them for at least a few months and have done the other lab work and ultrasound within that timeframe. – FP PCP

· eGFR value 35 or less

4

0

4

Well, the nephrologists have said [to refer for] a GFR for less than 35 …So I do. Period. But I have patients who don’t quite make that….clearly, somebody who has a big jump, without a reason for it, [needs] to have a conversation with the nephrologist, or a referral to the nephrologist. - FP PCP

If in the CKD3 range then just continuing the counseling, lifestyle modifications, and monitoring. And then if it’s dipping into the CKD4 where they’re down in that like 15 to 30 range, I’m thinking renal referral [to Nephrology]. – FP PCP

· eGFR value 15 to 30

4

0

4

When they get down to the twenties or especially below, then I usually will refer. Or if they may be Stage 3, but for some reason they seem to be dropping rapidly… Although, usually I’ll work those up first myself. I’ll get an ultrasound and recheck them, and maybe take them off some possible medications and then see what happens. I do all that first, and only if nothing budges …, I usually then ask for a referral. – IM PCP

· Base it on creatinine not eGFR

0

1

1

So I don’t refer or ask for chart review from nephrology when eGFR is under 60 though…As far as referral, the threshold is probably closer to 2 on a creatinine. So I use creatinine in that respect. – IM PA

· did not offer typical cut-off value (based on trends over time)

4

1

5

I probably don’t have a set number, because it would depend on the whole picture of the patient I want to know if this is a new occurrence or if this is a trend. Is this particular patient a diabetic? If it’s an acute new problem, I would treat it differently than if it’s a chronic ongoing problem. – FP PA

Well, rather than a number, it is a trend… for a patient I’d be looking back and if he or she hadn’t changed much in a year, I wouldn’t be referring.–IM PCP

Overall Referral Patterns to Kidney Class

I definitely refer more to the class…I like them to go to the kidney class to learn more about how to protect their kidneys. – FP PA

· refer more to class now

1

1

2

· refer infrequently to occasionally

4

3

7

When people are anxious, I will refer to the class for reassurance purposes and education. But I don’t send a high percentage of patients to that class, and I don’t take advantage of that resource as often as I could. – IM PA

I’m aware of it, and I might have referred one person in the past couple of years but usually it’s for the lower GFR’s – like a low 30 – to have them look at their diet and things. But so far I haven’t used that class that much. – FP PCP

· never refers to class

2

0

2

I’ve never referred to the kidney class myself. I have the impression that patients who go to kidney class are really the ones who already saw the nephrologist, or if they [Nephrology] advise me in a chart [consult]… - IM PCP

· no awareness of class/did not mention

6

2

8

I didn’t even know about it [kidney class]… there you go, I learned something. – IM PCP