Nephrology referral - Does my patient need it? Disclosure

Transcription

1 Nephrology referral - Does my patient need it? Sophia Chou, MD MSc March 10, 2018 Faculty: Sophia Chou Disclosure Relationships with commercial interest: None Potential conflict of interest: None 1

2 Objectives 1. To understand the purpose of CKD risk stratification and available tools 2. To describe implementation of kidney failure risk equation in managing nephrology referral 3. To identify point of care resource in providing CKD care 63 years old man 2

3 CKD Patients are More Likely to Die than Progress to ESRD Percentage of Patients 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 14.9% 16.2% 10.3% 6.6% 27.8% 5-Year Mortality Rate 64.2% 63.3% 74.8% 19.9% 1.0% 1.2% 45.7% 19.5% 24.3% 10.2% Stage 1 Stage 2 Stage 3 Stage 4 Disenrolled Event free RRT Died RRT = renal replacement therapy N=27998 Keith D et al. Arch Int Medicine 2004;164: CKD and the Nephrologist: GFR Categories (ml/min x 1.73 m2) G 1 > 90 G G 3a G 3b G G 5 < 15 Renal Failure Albuminuria Categories (mg/g creatinine) A1 A2 A3 < > 300 usually defined by RRT Nephrology Responsibility 3

4 Risk prediction in CKD Courtesy: Dr. Brenda Hemmelgarn 4 Variables: age, sex, egfr, ACR Concern re: validity in other settings (nonreferred) and ethnicities JAMA

5 Thirty one cohorts, including 721,357 participants with CKD Stages 3 to 5 in more than 30 countries spanning 4 continents, and showed that The original KFREs accurately predict the risk of progression from CKD Stages 3-5 to kidney failure in a diverse group of patients with CKD Tangri et al. JAMA 2016 Kidney Failure Risk Equation is implemented in Calgary multi-disciplinary Kidney Care clinic Can we apply this tool in non-referred population? 5

6 Calgary Zone Nephrology Referral Year # referral per month Long wait list for routine referrals Some referrals have low risk of progression Resource allocation Collaboration with primary care < 3% risk in 5 years: ~ 40% referrals Significantly decreased wait time Advances in Chronic Kidney Disease, Vol 23, No 4 (July), 2016: pp

7 KFRE in non-urgent referrals Define low risk as < 3% in 5 years Exclude: Age < 40yo Hematuria Hereditary d Autoimmune dx Pregnancy Metabolic abn / stones egfr < 30 Letter with recommendations and CKD resources to referring MD and referral is closed Implemented in Aug 2017 As of Jan 2018, 108 low risk referrals were closed Positive feedback from referring MD Reduced median wait time for routine appointments 167 days in days in days 7

8 Multi phased Intervention KFRE low risk Phone Clinic Specialist Link ereferral Nephrology Advice Request Nephrology Referral Face to Face Consultation Calgary Nephrology Referral Phone clinic KFRE letter January February March April May June July August September October November December January New Referral Released Wait list 8

9 Quality improvement Process 1. Define Opportunity Large number of Nephrology referrals Long wait lists KFRE implementation in CKD care ereferral 2. Build Understanding Not all referrals require consultation Not all CKD are at risk of progression Primary care engagement Winnipeg experiences 3. Act to Improve Phone clinic Implementation of KFRE Letter 4. Sustain Results Tracking metrics Physician survey 63 years old man 9

10 Referral is recommended: egfr < 30 ml/min/1.73m 2, irrespective of albuminuria or hematuria Persistent albuminuria (ACR > 60 mg/mmol), irrespective of hematuria Hematuria sustained and not readily explained by a urinary tract source with: Persistent albuminuria (ACR 3 60 mg/mmol) irrespective of egfr - or - egfr < 60 ml/min/1.73m 2 An unexplained, progressive decline in egfr 5 ml/min/1.73m 2 that occurs over 6 months 10

11 Objectives 1. To understand the purpose of CKD risk stratification and available tools 2. To describe implementation of kidney failure risk equation in managing nephrology referral 3. To identify point of care resource in providing CKD care Acknowledgement Robin Tomlinson Nadine Anheliger Kin Tam & Central Access & Triage team Nathan Gallagher & PARIS IT Team Natalie Ilkiw Calgary Nephrology Division Dr. Aminu Bello 11