Nephrology eConsults for Primary Care Providers: Original Investigation

Patient Care Gaps Prior to Maintenance Dialysis Initiation: A Population-Based Retrospective Study

Background

Guidelines in Ontario, Canada, recommend timely referral for multidisciplinary kidney care to facilitate planned dialysis initiation. Many patients do not receive recommended multidisciplinary kidney care prior to dialysis.

Objective

To better understand why this gap in pre-dialysis care exists, we conducted a study to describe the pathways by which patients initiate maintenance dialysis.

Design

A retrospective cohort study.

Setting

Population-based, using health care administrative databases from Ontario, Canada.

Patients

Adults initiating maintenance dialysis from April 2016 to March 2019.

Measurements and methods

Patients were grouped based on whether they received recommended multidisciplinary kidney care prior to dialysis initiation (at least 1 year of care with at least 2 visits). For those who did not receive recommended care, we grouped patients as having no identified care gap or into the following groups: (1) lack of timely chronic kidney disease (CKD) screening, (2) late nephrology referral (<1 year), or (3) late or no referral for multidisciplinary kidney care among patients followed by a nephrologist for at least 1 year.

Results

A total of 9216 patients were included with a mean (standard deviation) age of 66 (15) years, and 61.5% were male. Of the total, 896 (9.7%) patients died, 7671 (83.2%) remained on dialysis at 90 days, and 649 (7.0%) had stopped dialysis due to kidney function recovery within 90 days. Of the 9216 patients, 5434 (59%) had not received recommended multidisciplinary kidney care. Among those without recommended care, there were 2251 (41.4%) patients with no identified care gaps, 1351 (24.9%) patients with a lack of timely CKD screening, 359 (6.6%) patients with late nephrology referral, and 1473 (27.1%) patients with late or no referral for multidisciplinary kidney care.

Limitations

We could not determine if patients were referred but declined multidisciplinary kidney care.

Conclusions

More than half of patients had not received recommended multidisciplinary kidney care. Many patients experienced an acute decline in kidney function, which may not be preventable, but in others, there were missed opportunities for CKD screening or early referral to nephrology, or at the level of nephrology practice for early referral for multidisciplinary care. This work could be used to inform policies aimed at improving increased uptake of multidisciplinary kidney care prior to dialysis.

A retrospective analysis of the use of electronic consultation in general internal medicine

BACKGROUND

General internists in Canada are subspecialty providers in the inpatient and outpatient settings. Electronic consultations (eConsult) allow primary care providers (PCPs) to virtually consult specialists to address clinical questions. There is a paucity of literature examining the utility and benefits of eConsults by general internists.

AIMS

To determine how an eConsult service is used to access general internists.

METHODS

A retrospective cross-sectional analysis of internal medicine cases was completed between 1 January 2016 and 31 December 2019 via the ChamplainBASE eConsult service. Two authors derived and validated a general internal medicine (GIM)-specific taxonomy using the validated: (i) Taxonomy of Generic Clinical Questions; and (ii) Internal Classification for Primary Care. Two hundred seventy-six cases were coded following taxonomy validation. ChamplainBASE utilisation summary and closeout survey data were also analysed.

RESULTS

eConsults were responded to in a median of 3.1 days and took 15 min to complete. The eConsult's helpfulness and educational value were rated as 4 to 5/5 and often provided advice for a new or additional course of action. In-person referral was avoided in 40% of cases. The majority of eConsults consisted of a single question (88%) related to diagnostic clarification. The median remuneration per eConsult was $50.

CONCLUSIONS

The majority of eConsults to general internists sought diagnostic clarification and confirmed the view of general internists as expert diagnosticians. eConsults cost less than an in-person consultation and were viewed favourably by PCPs. Further research can consider the eConsult provider experience and whether eConsults should become a required part of GIM ambulatory practice.

Disparities in ethnicity and metabolic disease burden in referrals to nephrology

Introduction

The profile of patients referred from primary to tertiary nephrology care is unclear. Ethnic Malay patients have the highest incidence and prevalence of kidney failure in Singapore. We hypothesised that there is a Malay predominance among patients referred to nephrology due to a higher burden of metabolic disease in this ethnic group.

Methods

This is a retrospective observational cohort study. From 2014 to 2018, a coordinator and physician triaged patients referred from primary care, and determined co-management and assignment to nephrology clinics. Key disease parameters were collated on triage and analysed.

Results

A total of 6,017 patients were studied. The mean age of patients was 64 ± 16 years. They comprised 57% men; 67% were Chinese and 22% were Malay. The proportion of Malay patients is higher than the proportion of Malays in the general population (13.4%) and they were more likely than other ethnicities to have ≥3 comorbidities, including diabetes mellitus, hypertension, hyperlipidaemia, coronary artery disease and stroke (70% vs. 57%, P < 0.001). Malay and Indian patients had poorer control of diabetes mellitus compared to other ethnicities (glycated haemoglobin 7.8% vs. 7.4%, P < 0.001). Higher proportion of Malay patients compared to other ethnicities had worse kidney function with estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m2 on presentation (28% vs. 24%, P = 0.003). More ethnic Malay, Indian and younger patients missed appointments.

Conclusion

A disproportionately large number of Malay patients are referred for kidney disease. These patients have higher metabolic disease burden, tend to miss appointments and are referred at lower eGFR. Reasons underpinning these associations should be identified to facilitate efforts for targeting this at-risk population, ensuring kidney health for all.

Utility of eConsults for COVID-19 vaccine-related concerns in Ontario: a cross-sectional analysis

BACKGROUND

The Champlain BASE™ and Ontario eConsult services are virtual platforms that serve to facilitate contact between primary care providers and specialists across Ontario, relaying patient-specific questions to relevant specialists via a secure web-based platform. Despite ample evidence regarding the general effectiveness of these platforms, their utility as it pertains to clinical concerns regarding COVID-19 vaccines has not yet been explored.

METHODS

We performed a cross-sectional descriptive analysis of COVID-19 vaccine related eConsults on Ontario patients completed by five allergy specialists between February and October of 2021. 4318 COVID-19 vaccine-related eConsults were completed in total during this time; with 1857 completed by the five allergists participating in this analysis. Question types/content were categorized using a taxonomy developed through consensus on a weighted monthly sample of 499 total cases. Data regarding whether external resources were required to answer each eConsult, impact on primary care provider referral decisions, and allergy consultant response times were collected. A 2-question survey was completed by primary care providers following eConsultation and results were collected.

RESULTS

41.08% of eConsults received involved safety concerns regarding COVID-19 vaccine administration in the setting of prior allergic disease and another 36.1% involved a potential reaction the first dose of a COVID-19 vaccine. 72.1% of eConsults were answered by specialist without needing external resources, and only 9.8% of all eConsults received resulted in a recommendation for formal in-person referral to Clinical Immunology & Allergy specialist or another subspecialty. Average time to complete eConsult was 16.4 min, and 79.7% of PCP eConsult queries which would have traditionally resulted in formal consultation were resolved based on advice provided in the eConsult without need for in-person assessment.

CONCLUSIONS

Our study demonstrates the utility of the eConsult service as it pertains to COVID-19 vaccine-related concerns. The eConsult platform proved an effective tool in diverting the need for in-person assessment by an Allergist or other medical specialty. This is significant given the large volume of eConsults completed by Allergists, and demonstrates the impact of an effective electronic delivery of care model during a time of strained resources and public health efforts directed at mass vaccination.

Complex Interventions Across Primary and Secondary Care to Optimize Population Kidney Health: A Systematic Review and Realist Synthesis to Understand Contexts, Mechanisms, and Outcomes

BACKGROUND

CKD affects 850 million people worldwide and is associated with high risk of kidney failure and death. Existing, evidence-based treatments are not implemented in at least a third of eligible patients, and there is socioeconomic inequity in access to care. While interventions aiming to improve delivery of evidence-based care exist, these are often complex, with intervention mechanisms acting and interacting in specific contexts to achieve desired outcomes.

METHODS

We undertook realist synthesis to develop a model of these context-mechanism-outcome interactions. We included references from two existing systematic reviews and from database searches. Six reviewers produced a long list of study context-mechanism-outcome configurations based on review of individual studies. During group sessions, these were synthesized to produce an integrated model of intervention mechanisms, how they act and interact to deliver desired outcomes, and in which contexts these mechanisms work.

RESULTS

Searches identified 3371 relevant studies, of which 60 were included, most from North America and Europe. Key intervention components included automated detection of higher-risk cases in primary care with management advice to general practitioners, educational support, and non-patient-facing nephrologist review. Where successful, these components promote clinician learning during the process of managing patients with CKD, promote clinician motivation to take steps toward evidence-based CKD management, and integrate dynamically with existing workflows. These mechanisms have the potential to result in improved population kidney disease outcomes and cardiovascular outcomes in supportive contexts (organizational buy-in, compatibility of interventions, geographical considerations). However, patient perspectives were unavailable and therefore did not contribute to our findings.

CONCLUSIONS

This systematic review and realist synthesis describes how complex interventions work to improve delivery of CKD care, providing a framework within which future interventions can be developed. Included studies provided insight into the functioning of these interventions, but patient perspectives were lacking in available literature.

PODCAST

This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_05_08_CJN0000000000000136.mp3.

Preliminary evaluation of an inter-professional e-consultation on vaccines

The aim of this study was to assess the preliminary effectiveness and acceptability of an inter-professional e-consultation on vaccines. We used a quasi-experimental design to introduce an application in electronic health records that allowed primary health providers to launch e-consults to the hospital vaccines unit. A total of 135 e-consults were received during 10 months. E-consults were more frequently about subjects with chronic diseases (82.2%). Most of the e-consults were global (60.7%), that is, to revise a patient's complete vaccination schedule, whereas 39.3% were specific, that is, to request information regarding a concrete vaccine or serology, with hepatitis vaccines leading the ranking (42.9%). The e-consultation avoided hospital referral in 85.4% of the global e-consults and in 100% of the specific e-consults. Indicators of acceptability were all above nine points (10 points indicated the maximum). The best-rated aspect was the level of recommendation (9.7 ± 0.68 points). In summary, linking primary health-care providers with specialists in vaccines through an e-consultation tool is effective and well-accepted by users.

Trends in nephrology referral patterns for patients with chronic kidney disease: Retrospective cohort study

Introduction

Information on early, guideline discordant referrals in nephrology is limited. Our objective was to investigate trends in referral patterns to nephrology for patients with chronic kidney disease (CKD).

Methods

Retrospective cohort study of adults with ≥1 visits to a nephrologist from primary care with ≥1 serum creatinine and/or urine protein measurement <180 days before index nephrology visit, from 2006 and 2019 in Alberta, Canada. Guideline discordant referrals were those that did not meet ≥1 of: Estimated glomerular filtration rate (eGFR) ˂ 30 mL/min/1.73m², persistent albuminuria (ACR ≥ 300 mg/g, PCR ≥ 500 mg/g, or Udip ≥ 2+), or progressive and persistent decline in eGFR until index nephrology visit (≥ 5 mL/min/1.73m²).

Results

Of 69,372 patients with CKD, 28,518 (41%) were referred in a guideline concordant manner. The overall rate of first outpatient visits to nephrology increased from 2006 to 2019, although guideline discordant referrals showed a greater increase (trend 21.9 per million population/year, 95% confidence interval 4.3, 39.4) versus guideline concordant referrals (trend 12.4 per million population/year, 95% confidence interval 5.7, 19.0). The guideline concordant cohort were more likely to be on renin-angiotensin system blockers or beta blockers (hazard ratio 1.14, 95% confidence interval 1.12, 1.16), and had a higher risk of CKD progression (hazard ratio 1.09, 95% confidence interval 1.06, 1.13), kidney failure (hazard ratio 7.65, 95% confidence interval 6.83, 8.56), cardiovascular event (hazard ratio 1.40, 95% confidence interval 1.35,1.45) and mortality (hazard ratio 1.58, 95% confidence interval 1.52, 1.63).

Conclusions

A significant proportion nephrology referrals from primary care were not consistent with current guideline-recommended criteria for referral. Further work is needed to identify quality improvement initiatives aimed at enhancing referral patterns of patients with CKD.

Healthcare professionals' perspectives on facilitators of and barriers to CKD management in primary care: a qualitative study in Singapore clinics

INTRODUCTION

The burden of chronic kidney disease (CKD) is rising globally including in Singapore. Primary care is the first point of contact for most patients with early stages of CKD. However, several barriers to optimal CKD management exist. Knowing healthcare professionals' (HCPs) perspectives is important to understand how best to strengthen CKD services in the primary care setting. Integrating a theory-based framework, we explored HCPs' perspectives on the facilitators of and barriers to CKD management in primary care clinics in Singapore.

METHODS

In-depth interviews were conducted on a purposive sample of 20 HCPs including 13 physicians, 2 nurses and 1 pharmacist from three public primary care polyclinics, and 4 nephrologists from one referral hospital. Interviews were audio recorded, transcribed verbatim and thematically analyzed underpinned by the Theoretical Domains Framework (TDF) version 2.

RESULTS

Numerous facilitators of and barriers to CKD management identified. HCPs perceived insufficient attention is given to CKD in primary care and highlighted several barriers including knowledge and practice gaps, ineffective CKD diagnosis disclosure, limitations in decision-making for nephrology referrals, consultation time, suboptimal care coordination, and lack of CKD awareness and self-management skills among patients. Nevertheless, intensive CKD training of primary care physicians, structured CKD-care pathways, multidisciplinary team-based care, and prioritizing nephrology referrals with risk-based assessment were key facilitators. Participants underscored the importance of improving awareness and self-management skills among patients. Primary care providers expressed willingness to manage early-stage CKD as a collaborative care model with nephrologists. Our findings provide valuable insights to design targeted interventions to enhance CKD management in primary care in Singapore that may be relevant to other countries.

CONCLUSIONS

The are several roadblocks to improving CKD management in primary care settings warranting urgent attention. Foremost, CKD deserves greater priority from HCPs and health planners. Multipronged approaches should urgently address gaps in care coordination, patient-physician communication, and knowledge. Strategies could focus on intensive CKD-oriented training for primary care physicians and building novel team-based care models integrating structured CKD management, risk-based nephrology referrals coupled with education and motivational counseling for patients. Such concerted efforts are likely to improve outcomes of patients with CKD and reduce the ESKD burden.

The Use of Electronic Consultations in Outpatient Surgery Clinics: Synthesized Narrative Review

BACKGROUND

Electronic consultations (eConsults) are an increasingly used form of telemedicine that allows a nonspecialist clinician to seek specialist advice remotely without direct patient-specialist communication. Surgical clinics may see benefits from such forms of communication but face challenges with the need for intervention planning.

OBJECTIVE

We aimed to use the Quadruple Aim Framework to integrate published knowledge of surgical outpatient eConsults with regard to efficacy, safety, limitations, and evolving use in the era of COVID-19.

METHODS

We systematically searched for relevant studies across four databases (Ovid MEDLINE, Embase, Scopus, and Web of Science) on November 4, 2021, with the following inclusion criteria: English language, published in the past 10 years, and data on the outcomes of outpatient surgical eConsults.

RESULTS

A total of 363 studies were screened for eligibility, of which 33 (9.1%) were included. Most of the included studies were from the United States (23/33, 70%) and Canada (7/33, 21%), with a predominant multidisciplinary focus (9/33, 27%). Most were retrospective audits (16/33, 48%), with 15% (5/33) of the studies having a prospective component.

CONCLUSIONS

The surgical eConsult studies indicated a possible benefit for population health, promising safety results, enhanced patient and clinician experience, and cost savings compared with the traditional face-to-face surgical referral pathway. Their use appeared to be more favorable in some surgical subspecialties, and the overall efficacy was similar to that of medical subspecialties. Limited data on their long-term safety and use during the COVID-19 pandemic were identified, and this should be the focus of future research.

Primary Care Psychiatry eConsults at a Rural Academic Medical Center: Descriptive Analysis

BACKGROUND

Primary care providers serve a crucial role in addressing the mental health needs of many patients. However, there are times when input from a psychiatric specialist may be helpful in supporting the mental health care provided in primary care. Psychiatry eConsults can serve as a valuable tool in providing specialist advice for primary care physicians when direct referral to specialty care is not readily available.

OBJECTIVE

The goal of this study is to evaluate the content and implementation of psychiatric eConsults by primary care providers in a rural academic medical center.

METHODS

This is a retrospective review of 343 eConsults placed between May 2016 and February 2019 by primary care providers at a single academic medical center. The content of eConsult requests, including patient diagnosis, consult question type, specialist recommendations, patient demographics, the distance of patient and primary care providers from the consulting provider, rate of implementation of the recommendation, and response time, were analyzed.

RESULTS

The most common diagnoses associated with eConsults were depression (162/450, 36%) and anxiety (118/450, 26%). The most commonly asked eConsult question was regarding medication management, including medication choice, side effects, interactions, and medication taper (288/343, 84%). More than one recommendation was included in 76% (259/343) of eConsults, and at least one recommendation was implemented by the primary care provider in 94% (282/300) of eConsults. The average time to respond to an eConsult was 26 hours.

CONCLUSIONS

This study demonstrates that psychiatry eConsults can be conducted in a timely manner and that primary care providers implement the recommendations at a high rate.

Enhancing clinical judgement in virtual care for complex chronic disease

The COVID-19 pandemic has transformed traditional in-person care into a new reality of virtual care for patients with complex chronic disease (CCD), but how has this transformation impacted clinical judgement? I argue that virtual specialist-patient interaction challenges clinical reasoning and clinical judgement (clinical reasoning combined with statistical reasoning). However, clinical reasoning can improve by recognising the abductive, deductive, and inductive methods that the clinician employs. Abductive reasoning leading to an inference to the best explanation or invention of an explanatory hypothesis is the default response to unfamiliar or confusing situations. Deductive reasoning supports a previously established goal, but deductive accuracy requires sound premises leading to a valid conclusion. Inductive reasoning uses efficient data sorting, data interpretation, and plan creation without a previously established goal, and allows assessing inferential accuracy over time. In all cases, communication remains the backbone of the clinical encounter. Virtual care for CCD challenges clinical judgement by reducing available information, so even experienced specialists who use induction might default to deduction or abduction. The visit might shorten, decreasing narrative competence and in-turn management quality. Clinical judgement in virtual encounters can be enhanced by allowing sufficient time, employing allied health staff, using an advance script, avoiding dogmatic commitment to either virtual or in-person encounters, special training in virtual care, and conscious awareness of abductive, deductive, and inductive reasoning processes. Clinical judgement in virtual encounters especially calls for Gestalt cognition to assess a situational pattern irreducible to its parts and independent of its particulars, so that efficient data interpretation and self-reflection are enabled. Gestalt cognition integrates abduction, deduction, and induction, appropriately divides the time and effort spent on each, and can compensate for reduced available information. Evaluating one's clinical judgement for those components especially vulnerable to compromise can help optimize the delivery of virtual care for patients with CCD.

Electronic consultations (E-consults) and their outcomes: a systematic review

OBJECTIVE

Electronic consultations (e-consults) are clinician-to-clinician communications that may obviate face-to-face specialist visits. E-consult programs have spread within the US and internationally despite limited data on outcomes. We conducted a systematic review of the recent peer-reviewed literature on the effect of e-consults on access, cost, quality, and patient and clinician experience and identified the gaps in existing research on these outcomes.

MATERIALS AND METHODS

We searched 4 databases for empirical studies published between 1/1/2015 and 2/28/2019 that reported on one or more outcomes of interest. Two investigators reviewed titles and abstracts. One investigator abstracted information from each relevant article, and another confirmed the abstraction. We applied the GRADE criteria for the strength of evidence for each outcome.

RESULTS

We found only modest empirical evidence for effectiveness of e-consults on important outcomes. Most studies are observational and within a single health care system, and comprehensive assessments are lacking. For those outcomes that have been reported, findings are generally positive, with mixed results for clinician experience. These findings reassure but also raise concern for publication bias.

CONCLUSION

Despite stakeholder enthusiasm and encouraging results in the literature to date, more rigorous study designs applied across all outcomes are needed. Policy makers need to know what benefits may be expected in what contexts, so they can define appropriate measures of success and determine how to achieve them.

The Impact of a New Triage and Booking System on Renal Clinic Wait Times

Background:

Prolonged wait times are known barriers to accessing nephrology care for patients needing more urgent specialist services. Improved process and standardized triage systems are known to minimize wait times of urgent or semi-urgent care in health care disciplines. In Central Zone (CZ) renal clinic, mean wait times for urgent (P1) and semi-urgent (P2) referrals were prolonged before 2014. We also observed prolonged wait times for elective (P3-P5) categories. Improving wait times was identified as an access to care quality improvement focus in CZ renal clinic of the Nova Scotia Health Authority (NSHA).

Objectives:

To describe our new referral process and new triage system, and to examine their effect on number of referrals wait-listed and mean wait times.

Design:

A quasi-experimental design was used.

Setting:

Halifax, Nova Scotia, Canada.

Participants:

Patients referred to Central Zone Renal Clinic between 2012 and 2018.

Measurements:

A time series of referral counts and wait times for each triage category were measured before our interventions and after implementing our interventions.

Methods:

We reviewed our referral processes to identify gaps leading to prolonged wait times. On January 1, 2014, we implemented new administrative procedures: pretriage (standardized referral information form and staff training), triage (standardized clinic intake criteria and new triage guidelines), posttriage (protecting clinic spots for urgent and semi-urgent referrals, wait-list maintenance, and increasing new referral clinic capacity). Data were collected prospectively. Descriptive analysis on mean wait times was done using run charts.

Results:

A 33% reduction in total number of referrals wait-listed was observed over 4.5 years after intervention. Descriptive analysis of the urgent and semi-urgent categories (P1 and P2) revealed a significant shift of mean wait times on run charts after the interventions. Target wait time was achieved in 94% of P1 category and 78% of P2 category.

Limitations:

This type of study design does not exclude confounding variables influencing results. We did not explore stakeholder satisfaction or whether the new referral process presented barriers to resending referrals that had insufficient triage data. The long-term sustainability of adding demand-responsive surge clinics and opportunity cost were not assessed. Our referral process and triage system have not been externally validated and may not be applicable in settings without wait-lists or settings that use electronic, telephone or telemedicine consults.

Conclusion:

Our selective intake of referrals with adequate triage information and referrals needing nephrology consult as defined by our clinic intake criteria reduced number of referrals wait-listed. We saw improved wait times for urgent and semi-urgent referrals with these categories now falling within target wait times for the vast majority of patients. The work of this improvement initiative continues especially for the lower-risk triage categories.

Trial registration:

Not applicable as this was a Quality improvement initiative.

Protocol: Improving Access to Specialist Nephrology Care Among Rural/Remote Dwellers of Alberta: The Role of Electronic Consultation in Improving Care for Patients With Chronic Kidney Disease

Background:

As the burden of chronic kidney disease (CKD) continues to increase, many geographically dispersed Canadians have limited access to specialist nephrology care, which tends to be centralized in major urban areas. As a result, many rural/remote-dwellers in Canada experience poor quality of care and related adverse outcomes. It is imperative to develop alternative care delivery mechanisms to ensure optimal health outcomes for all Canadians.

Objective:

To investigate the feasibility and effectiveness of electronic consultation (eConsult) as a new model for interactions between specialists and primary care providers (PCPs) to improve access to care for patients with CKD.

Design:

This is a sequential, mixed methods study that will be conducted in 3 phases.

Setting:

The study will be conducted across the entire province of Alberta, supported by Alberta Kidney Care (formerly, Northern and Southern Alberta Renal Programs [NARP/SARP]).

Patients:

Patients suffering from CKD will be included in the study.

Measurements:

We will assess the barriers and enablers of implementation and adoption of an e-consultation protocol to facilitate access to care for patients with CKD in Alberta with a focus on rural/remote-dwellers with CKD. We will also evaluate the impact of the eConsult system (eg, improved access to specialist care, reduction in care gaps), assess the feasibility of province-wide implementation, and compare eConsult with practice facilitation versus eConsult alone in terms of access to specialist care, quality of care, and related outcomes.

Methods:

The study will be conducted in 3 phases. In phase 1, we will assess the perceptions of stakeholders (ie, PCPs, nephrologists, patients, policymakers, and other care providers) to improve CKD care delivery, quality, and outcomes in Alberta with focus groups and semistructured interviews. Phase 2 will engage specific family physicians for their input on key factors and logistical issues affecting the feasibility of implementing eConsult for the care of patients with CKD. Phase 3 will provide academic detailing including practice facilitation to clinics in Alberta to assess how eConsult with practice facilitation compares with eConsult alone in terms of access to specialist care, quality of care, and related outcomes.

Results:

We will assess stakeholder perceptions about potential barriers to and enablers of a new eConsult and decision support system strategy, focusing on elements that are most important for the design of a feasible and implementable intervention. We will develop, pilot test, and assess the impact of the eConsult model in improving access to specialist nephrology care and the feasibility of province-wide implementation. The final phase of the project will address key challenges for optimal care for patients with CKD living in rural, remote, and underserved areas of Alberta, particularly timely referral and disease management as well as the cost-effective benefits of eConsult.

Limitations:

Lack of high-speed Internet in many rural and remote areas of Alberta may lead to more time spent in completing the eConsult request online versus faxing a referral the traditional way. Allied health care staff (referral coordinators, administrative staff) require training to the eConsult system, and physicians at many remote sites do not have adequate staff to handle eConsult as an added task.

Conclusions:

Implementation of eConsult can favorably influence referral patterns, access to care, care quality, patient outcomes, and health care costs for people with CKD. Results of this study will inform the optimization of care for rural/remote-dwellers with CKD and will facilitate future partnerships with policymakers and provincial renal programs in Alberta to ensure optimal kidney health for all residents.

Trial registration:

Not required.

Capacity of Kidney Care in Canada: Identifying Barriers and Opportunities

BACKGROUND

Chronic kidney disease (CKD) is a significant health problem in Canada. Understanding the capacity of the Canadian health-care system to deliver kidney care is important to provide optimal care.

OBJECTIVE

To compare Canada's position in relation to countries of similar economic standing.

DESIGN

Cross-sectional electronic survey.

SETTING

Member countries of the Organisation for Economic Co-operation and Development (OECD) that participated in the survey.

PARTICIPANTS

Nephrologists, other physicians, policymakers, and other professionals with relevant expertise in kidney care.

MEASUREMENTS

Not applicable.

METHODS

A survey administered by the International Society of Nephrology assessed the global capacity of kidney care delivery. Data from participating OECD countries were analyzed using descriptive statistics to compare Canada's position.

RESULTS

Of the participating countries, most funded kidney care services (non-medication) by government (transplantation: 85%, dialysis: 81%, acute kidney injury (AKI): 77%). Most countries covered medication. Canada reported a public funding model for kidney services and a mix of public and private sources for medication. Nephrologists and nephrology trainee densities were lower in Canada compared to the median (15.33 vs. 25.82 and 1.74 vs. 3.94, respectively). CKD was recognized as a health priority in five countries, but not in Canada. Registries for CKD did not exist in most (24/26) countries. Canada followed a national strategy for noncommunicable diseases, but this was not specific to CKD care, dialysis, or transplantation.

LIMITATIONS

Risks of recall bias or social desirability bias are present. Differences in a number of factors could influence discrepancies among countries and were not explored. Responses reflected the existence of practices, policies, and strategies, and may not necessarily describe action or impact. Capacity of care is not equal across all regions and provinces within Canada; however, the findings are reported on a national level and therefore may not appropriately address variability.

CONCLUSIONS

This study describes the capacity for kidney care at a national level within the context of the Canadian health system. The Canadian health-care system is well funded by the government; however, there are areas that could be improved to increase the optimization of kidney care provided.

Primary Care Physicians' Perceived Barriers to Nephrology Referral and Co-management of Patients with CKD: a Qualitative Study

BACKGROUND

Effective co-management of patients with chronic kidney disease (CKD) between primary care physicians (PCPs) and nephrologists is increasingly recognized as a key strategy to ensure the delivery of efficient and high-quality CKD care. However, the co-management of patients with CKD remains suboptimal.

OBJECTIVE

We aimed to identify PCPs' perceptions of key barriers and facilitators to effective co-management of patients with CKD at the PCP-nephrology interface.

STUDY DESIGN

Qualitative study SETTING AND PARTICIPANTS: Community-based PCPs in four US cities: Baltimore, MD; St. Louis, MO; Raleigh, NC; and San Francisco, CA APPROACH: We conducted four focus groups of PCPs. Two members of the research team coded transcribed audio-recorded interviews and identified major themes.

KEY RESULTS

Most of the 32 PCPs (59% internists and 41% family physicians) had been in practice for > 10 years (97%), spent ≥ 80% of their time in clinical care (94%), and practiced in private (69%) or multispecialty group practice (16%) settings. PCPs most commonly identified barriers to effective co-management of patients with CKD focused on difficulty developing working partnerships with nephrologists, including (1) lack of timely adequate information exchange (e.g., consult note not received or CKD care plan unclear); (2) unclear roles and responsibilities between PCPs and nephrologists; and (3) limited access to nephrologists (e.g., unable to obtain timely consultations or easily contact nephrologists with concerns). PCPs expressed a desire for "better communication tools" (e.g., shared electronic medical record) and clear CKD care plans to facilitate improved PCP-nephrology collaboration.

CONCLUSIONS

Interventions facilitating timely adequate information exchange, clear delineation of roles and responsibilities between PCPs and nephrologists, and greater access to specialist advice may improve the co-management of patients with CKD.

Barriers and facilitators for implementation of electronic consultations (eConsult) to enhance specialist access to care: a scoping review protocol

INTRODUCTION

Electronic consultations (eConsult), asynchronous exchanges of patient health information at a distance, are increasingly used as an option to facilitate patient care and collaboration between primary care providers and specialists. Although eConsult has demonstrated success in increasing efficiency in the referral process and enhancing access to care, little is known about the factors influencing its wider adoption and implementation by end users. In this paper, we describe a protocol to conduct a scoping review of the literature on the barriers and facilitators to a wider adoption and implementation of eConsult service.

METHODS AND ANALYSIS

This scoping review will be based on the framework pioneered by Arksey and O'Malley and later developed by Levac et al. We will use the guidance for scoping reviews developed by the Joanna Briggs Institute to report our findings. In addition to several electronic databases (Medline, Embase, Cochrane Library, CINAHL, EBSCOhost and PsycINFO) studies will be identified by including relevant grey literature. Two reviewers will independently screen titles and full texts for inclusion. Studies reporting on barriers and/or facilitators in settings similar to eConsult will be included. Data on study characteristics and key barriers and facilitators will be extracted. Data will be analysed thematically and classified using the Quadruple Aim framework.

ETHICS AND DISSEMINATION

Approval by research ethics board is not required since the review will only include published and publicly accessible data. Review findings will be used to inform future studies and the development of practice tools to support the wider adoption and success of eConsult implementation. We plan to publish our findings in a peer-reviewed journal and develop a useful and accessible summary of the results.