Table 5 Suggestions for Future Needs to Improve Utilization of eGFR Value and Overall CKD Management (n = 19)

Ongoing Provider Education

It would be nice to get a little lecture on it, and to talk to a nephrologist one-on-one… Or if they could do it, they could make one of those DVD kinds of things and you can tune in or watch at home. - IM PCP

· yearly trainings both in-person and on-line

· trainings to focus on: why use eGFR; how to best use it at different states/values; how to best communicate and educate patients at different values/stages

I’d like to know if the eGFR so sensitive that it’s going to give some false positives, what’s the rate of those that are occurring? And how does our computer monitoring systems handle that… I would like to know more about that. – NP IM

· provide case-study approach highlighting different patient scenarios

A good topic to have at one of our CME presentations would be a talk about it in a very case study practical sense; not as a lecture …but more like, okay, let’s look at this person… And just talk us through it, how it’s useful - just the practical use of GFR versus BUN, creatinine in a pure sense – that would be helpful…. – FP PA

· provide both opportunity and responses to provider questions/concerns

Regular Feedback from Nephrology to PCPs

So there still are questions around what do we miss by just getting a UA and an ultrasound? Is there something more we’re missing, before we send them to the nephrologist and they go on dialysis? What if we’re missing a multiple myeloma or vasculitis, which can be treated before they were sent to the nephrologist. …that’s the type of question I have, ‘Are we getting everything with that UA and the baseline ultrasound?’ – IM PCP

· Provide yearly to twice yearly feedback on the provider’s actions related to such things as:

→ referral patterns to Nephrology appropriately – is it too much or coming too late

The Nephrology Department can see the referrals coming in, so they can see how providers, in general, [treat] kidney disease. Are we reasonable with our referrals?…Are we sending people too early or too late? It would be nice to know are there places where there’s room for improvement. I want to know whether I’m doing a reasonable job or not. – FP PCP

→ ordering patterns for follow up labs and tests - are the appropriate labs and tests being ordered at the appropriate times

→ identification of whether there is anything else the provider could be doing for the patient both prior to and after referral to Nephrology

If it’s [eGFR] in the fifties, should I monitor it every 6 months? In the forties, should I monitor it every 4 months? I don’t really know how often I should be monitoring the GFR. And then, when am I supposed to do any other evaluation for their kidneys? …I’m not sure when I’m supposed to do theses other follow up tests. – FP PA

Development of Provider Tools/Reminders

I had a nice little, laminated handout that came from Nephrology on guidelines and referrals. It has now gone missing, so it would be helpful to have that resent out again – it’s a very convenient and worthwhile thing to have. - PA IM

· update and re-send out laminated card summarizing current CKD guidelines and “best practice” referral patterns based on eGFR value

I guess I would like a dot phrase*. What should I tell these people? What does Nephrology want us to tell people with CKD? …So having a created dot phrase would be wonderful to put on the results to the patient, explaining what to expect and when to come back … - FM NP

· create several different letter templates and phone scripts (based on eGFR value and CKD staging) for use by providers and medical assistants in their discussions and communication with members

It might be really worthwhile to just reorient people, maybe once a year, with an email saying, this is why we’re doing eGFRs, we’ve got physic physician support accompanying that EGFR process, here is what we hope to end up doing with the data, and here’s how we manage those populations of people that are getting chronic kidney disease. - FM NP

· yearly reminders of where to access CKD guidelines on-line, and any changes in the guidelines

· yearly reminders of the Kidney class option, including where, when, and how often it occurs and the appropriate circumstances to refer patients to class

My suggestion would be to offer another quick link in the clinical practice guidelines to take you there to quickly find CKD guideline information. – FP PCP

I’d love to see a promotion about the kidney class, so that clinicians are more aware of it. … if they’d promote the kidney class and say, in general these classes are offered at[these] various times and locations, etc. -. that would help primary care, because we inevitably get those types of questions. – FP PCP

Improved Integration of GFR values into EMR/Other Web-based Tools

In primary care, we’ve set up this thing called Relevant Results. It can show up either on our scheduled page or when we open the patient’s chart. It gives the trend of three things, but we don’t have the GFR there. We just have the creatinine… it would be nice and helpful to have the GFR there as well. – FM PCP

· consistent, automatic process for eGFR value and follow ups to be reported in commonly used areas of the EMR – such as patient problem list; results reporting; and trended results

I would like a “decreased GFR” option for the problem list… When I put a problem in the problem list, I just have to pick something that is close to what I want, so for this I’ve chosen the ‘elevated creatinine’ option as a flag, but what I really want is a ‘decreased GFR’ option. -FM NP

· improve ability of computer to correctly impute race so providers and patients see only one eGFR value rather than both on lab results, outreach prompts, or patient letters

· continue to improve and refine smart set tools in the internal referral process of EMR to facilitate proper lab orders and follow up by providers

Patient-Related Education Tools

On the subject of kidney health, I would like some models, pictures, charts, those sorts of things that would be useful in discussion with patient - something that that you could use to pin to your wall and say, ‘Now here’s what a kidney looks like and this is the problem with the low GFR’, for example. – IM PA

· create standard, uniform hand-outs for providers to use with patients to help explain kidney functioning, meaning of eGFR values, and CKD staging

· create visual exam room posters of the kidneys and how they function to assist with provider communication and education to patients

I try to say to patients their kidneys aren’t failing, they’re just not functioning optimally. That part I don’t have worded right, because some of them tend to freak out about it, so I would like some help with wording that, and how to explain that to them…if we could just give them a packet, I think if they would read that, that might be helpful. But the wording, I would like some help with that, because I don’t seem to quite get that right. - FP PA

· improve patient information and education about CKD and kidney functioning on the organization’s external website

I would love to have a chronic kidney disease patient handout that gives the basic information. It would be good if we had a specialist-created, kind of supervised handout that we can give to patients that says, ‘Here’s what you should do to control your blood pressure, your diabetes if you have it; avoiding these substances that can be harmful to the kidneys. And here’s what you should do for nutrition, protein intake, water intake, etcetera’. And have that kind of be standardized… And that information could then also be easily found by patients online at KP.org, so if they’re looking for CKD information it is there online as well. – FP PCP