Simple clinical tools can promote coordination of care between primary care practitioners (PCPs) and nephrologists, resulting in improved documentation, diagnosis and referral of patients with chronic kidney disease, according to a new study in the January issue of the American Journal of Kidney Diseases.

"CKD is common and costly, both in terms of dollars and quality of life, and is mostly preventable," said William Haley, MD, the lead researcher with the Division of Nephrology and Hypertension at Mayo Clinic in Jacksonville, Fla. "Emerging evidence from a number of sources suggests that early interventions and improved care coordination between primary care practitioners (PCPs) and nephrologists results in better outcomes for patients. Practically everyone believes that coordination of care is important, but sadly, it is usually not happening."

This study, conducted at five nephrology clinics and their referring PCP practices in Philadelphia and Chicago, evaluated whether implementation of a set of standardized clinical management and communication tools could improve identification and management of CKD including care coordination between PCP and nephrology practices. The study introduced a CKD screening and referral protocol, and select specifically tailored tools from the Advanced CKD Patient Management Toolkit developed by the Renal Physicians Association into the PCP practice which resulted in improved processes for CKD identification, referral to nephrologists, communication, and execution of co-management plans. Overall GFR documentation by PCPs increased from 82% to 99% and the rate referral of patients with CKD stage 4 to a nephrologist increased.


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Post-intervention interviews with PCPs indicated an increased awareness of CKD risk factors, the need to track high-risk patients, and the importance of early referral. Final nephrologist interviews revealed heightened attention to communication and co-management with PCPs and increased levels of satisfaction among all parties.

The study also highlighted some of the friction that can exist between PCPs and nephrologists, and illustrated how simple tools can begin to address these underlying issues.

"We heard from PCPs about the time burden of screening and managing multiple conditions, and a perception of a lack of respect from specialists—a feeling of being relegated to do work that specialists choose not to do," said Haley. "Simply bringing nephrologists and PCPs together and beginning the conversation about CKD care and common goals for patients had a dramatic impact in changing these perceptions and improving care."

Researchers noted that the care of CKD patients has historically been suboptimal, highly variable, fragmented, inefficient, and rife with duplication of services and tests.

According to Haley, it is critical that PCPs take an active role in detecting and managing early kidney disease. It is estimated that 26 million people have CKD and many more are at risk to develop CKD due to diabetes, hypertension, or being over 60 years old. It is therefore essential that detection and prevention start with the PCP and as kidney disease progresses it becomes valuable to have the patient co-managed by their PCP and nephrologist.