Impact of quality improvement initiatives to improve CKD referral patterns: a systematic review protocol

INTRODUCTION

Chronic kidney disease (CKD) is a global-health problem. A significant proportion of referrals to nephrologists for CKD management are early and guideline-discordant, which may lead to an excess number of referrals and increased wait-times. Various initiatives have been tested to increase the proportion of guideline-concordant referrals and decrease wait times. This paper describes the protocol for a systematic review to study the impacts of quality improvement initiatives aimed at decreasing the number of non-guideline concordant referrals, increasing the number of guideline-concordant referrals and decreasing wait times for patients to access a nephrologist.

METHODS AND ANALYSIS

We developed this protocol by using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Protocols (2015). We will search the following empirical electronic databases: MEDLINE, Embase, Cochrane Library, CINAHL, Web of Science, PsycINFO and grey literature for studies designed to improve guideline-concordant referrals or to reduce unnecessary referrals of patients with CKD from primary care to nephrology. Our search will include all studies published from database inception to April 2021 with no language restrictions. The studies will be limited to referrals for adult patients to nephrologists. Referrals of patients with CKD from non-nephrology specialists (eg, general internal medicine) will be excluded.

ETHICS AND DISSEMINATION

Ethics approval will not be required, as we will analyse data from studies that have already been published and are publicly accessible. We will share our findings using traditional approaches, including scientific presentations, open access peer-reviewed platforms, and appropriate government and public health agencies.

PROSPERO REGISTRATION NUMBER

CRD42021247756.

The Delivery of Patient Care in Ontario's Family Health Teams during the First Wave of the COVID-19 Pandemic

OBJECTIVE

The objective of this paper was to identify continuations and changes in care delivery methods in primary care teams during the COVID-19 pandemic.

DESIGN

The study used a cross-sectional, web-based survey comprising close-ended and open-ended questions.

SETTING

The setting comprised family health teams (FHTs) across Ontario, Canada.

PARTICIPANTS

The participants included executive directors of FHTs or designates of their choosing.

SURVEY

Descriptive statistics were derived from responses to close-ended questions, and responses to open-ended questions were coded using thematic analysis.

RESULTS

With 93 participants, the response rate was 48%. Participants reported the continuation of in-person care, the implementation of virtual care across FHTs and collaboration within these teams and their communities.

Impact of the KidneyWise toolkit on chronic kidney disease referral practices in Ontario primary care: a prospective evaluation

OBJECTIVES

Chronic kidney disease (CKD) is common; therefore, coordination of care between primary care and nephrology is important. Ontario Renal Network's KidneyWise toolkit was developed to provide guidance on the detection and management of people with CKD in primary care (www.kidneywise.ca). The aim of this study was to evaluate the impact of the April 2015 KidneyWise toolkit release on the characteristics of primary care referrals to nephrology.

DESIGN AND SETTING

The study was a prospective pre-post design conducted at two nephrology sites (community site: Trillium Health Partners in Mississauga, Ontario, Canada, and academic site: St Joseph's Healthcare in Hamilton, Ontario, Canada). Referrals were compared during the 3-month time period immediately prior to, and during a 3-month period 1 year after, the toolkit release.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the change in proportion of referrals for CKD that met the KidneyWise criteria. Additional secondary referral and quality of care outcomes were also evaluated. Multivariable logistic regression was used to evaluate preselected variables for their independent association with referrals that met the KidneyWise criteria.

RESULTS

The proportion of referrals for CKD among people who met the KidneyWise referral criteria did not significantly change from pre-KidneyWise to post-KidneyWise implementation (44.7% vs 45.8%, respectively, adjusted OR 1.16, 95% CI 0.85 to 1.59, p=0.36). The proportion of referrals for CKD that provided a urine albumin-creatinine ratio significantly increased post-KidneyWise (25.8% vs 43.8%, adjusted OR 1.45, 95% CI 1.06 to 1.97, p=0.02). The significant independent predictors of meeting the KidneyWise referral criteria were academic site, increased age and use of the KidneyWise referral form.

CONCLUSIONS

We did not observe any change in the proportion of appropriate referrals for CKD at two large nephrology centres 1 year after implementation of the KidneyWise toolkit.

Medications Used Routinely in Primary Care to be Dose-Adjusted or Avoided in People With Chronic Kidney Disease: Results of a Modified Delphi Study

Background: Chronic kidney disease (CKD) affects up to 18% of those over the age of 65 years. Potentially inappropriate medication prescribing in people with CKD is common. Objectives: Develop a pragmatic list of medications used in primary care that required dose adjustment or avoidance in people with CKD, using a modified Delphi panel approach, followed by a consensus workshop. Methods: We conducted a comprehensive literature search to identify potential medications. A group of 17 experts participated in a 3-round modified Delphi panel to identify medications for inclusion. A subsequent consensus workshop of 8 experts reviewed this list to prioritize medications for the development of point-of-care knowledge translation materials for primary care. Results: After a comprehensive literature review, 59 medications were included for consideration by the Delphi panel, with a further 10 medications added after the initial round. On completion of the 3 Delphi rounds, 66 unique medications remained, 63 requiring dose adjustment and 16 medications requiring avoidance in one or more estimated glomerular filtration rate categories. The consensus workshop prioritized this list further to 24 medications that must be dose-adjusted or avoided, including baclofen, metformin, and digoxin, as well as the newer SGLT2 inhibitor agents. Conclusion and Relevance: We have developed a concise list of 24 medications commonly used in primary care that should be dose-adjusted or avoided in people with CKD to reduce harm. This list incorporates new and frequently prescribed medications and will inform an updated, easy to access source for primary care providers.

Quality of Chronic Kidney Disease Management in Canadian Primary Care

IMPORTANCE

Although patients with chronic kidney disease (CKD) are routinely managed in primary care settings, no nationally representative study has assessed the quality of care received by these patients in Canada.

OBJECTIVE

To evaluate the current state of CKD management in Canadian primary care practices to identify care gaps to guide development and implementation of national quality improvement initiatives.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study leveraged Canadian Primary Care Sentinel Surveillance Network data from January 1, 2010, to December 31, 2015, to develop a cohort of 46 162 patients with CKD managed in primary care practices. Data analysis was performed from August 8, 2018, to July 31, 2019.

MAIN OUTCOMES AND MEASURES

The study examined the proportion of patients with CKD who met a set of 12 quality indicators in 6 domains: (1) detection and recognition of CKD, (2) testing and monitoring of kidney function, (3) use of recommended medications, (4) monitoring after initiation of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs), (5) management of blood pressure, and (6) monitoring for glycemic control in those with diabetes and CKD. The study also analyzed associations of divergence from these quality indicators.

RESULTS

The cohort comprised 46 162 patients (mean [SD] age, 69.2 [14.0] years; 25 855 [56.0%] female) with stage 3 to 5 CKD. Only 4 of 12 quality indicators were met by 75% or more of the study cohort. These indicators were receipt of an outpatient serum creatinine test within 18 months after confirmation of CKD, receipt of blood pressure measurement at any time during follow-up, achieving a target blood pressure of 140/90 mm Hg or lower, and receiving a hemoglobin A1c test for monitoring diabetes during follow-up. Indicators in the domains of detection and recognition of CKD, testing and monitoring of kidney function (specifically, urine albumin to creatinine ratio testing), use of recommended medications, and appropriate monitoring after initiation of treatment with ACEIs or ARBs were not met. Only 6529 patients (18.4%) with CKD received a urine albumin test within 6 months of CKD diagnosis, and 3954 (39.4%) had a second measurement within 6 months of an abnormal baseline urine albumin level. Older age (≥85 years) and CKD stage 5 were significantly associated with not satisfying the criteria for the quality indicators across all domains. Across age categories, younger patients (aged 18-49 years) and older patients (≥75 years) were less likely to be tested for albuminuria (314 of 1689 patients aged 18-49 years [18.5%], 1983 of 11 919 patients aged 75-84 years [61.6%], and 614 of 5237 patients aged ≥85 years [11.7%] received the urine albumin to creatinine ratio test within 6 months of initial estimated glomerular filtration rate <60 mL/min per 1.73 m2; P < .001). Patients aged 18 to 49 years were less commonly prescribed recommended medications (222 of 2881 [7.7%]), whereas patients aged 75 to 84 years were prescribed ACEIs or ARBs most frequently (2328 of 5262 [44.2%]; P < .001).

CONCLUSIONS AND RELEVANCE

The findings suggest that management of CKD across primary care practices in Canada varies according to quality indicator. This study revealed potential priority areas for quality improvement initiatives in Canadian primary care practices.

Approach to the detection and management of chronic kidney disease: What primary care providers need to know

OBJECTIVE

To help primary care providers, both family physicians and nurse practitioners, identify, detect, and manage patients with and at risk of chronic kidney disease (CKD), as well as outline criteria for appropriate referral to nephrology.

SOURCES OF INFORMATION

Published guidelines on the topic of CKD and its comorbidities were reviewed. A MEDLINE search was conducted using the MeSH terms chronic renal insufficiency, family practice, and primary health care. The search was limited to reviews and articles in English. The search covered all relevant articles from 2006 to the present.

MAIN MESSAGE

The KidneyWise clinical tool kit, created by the Ontario Renal Network and available at www.kidneywise.ca, provides evidence-informed, practical guidance to primary care providers on the diagnosis and management of CKD. A component of this tool is an algorithm that offers a step-by-step approach to diagnosing and managing CKD. This resource will help empower providers to identify those at high risk of this condition, order appropriate diagnostic tests, help prevent further disease progression, and reduce comorbid cardiovascular risk in patients with CKD.

CONCLUSION

Most patients with CKD can be managed in primary care. Serial follow-up is essential to identify patients at high risk of progression to advanced stages of CKD, including end-stage renal disease. Primary care providers must continue to work together with local nephrologists to improve the lives of those living with CKD.

Approach to management of suspected rabies exposures: what primary care physicians need to know

OBJECTIVE

To review the role of primary care physicians, in conjunction with local public health units, in the management of suspected rabies exposures and to outline the current guidelines for the administration of rabies postexposure prophylaxis.

SOURCES OF INFORMATION

Published guidelines on the topic of rabies were reviewed and additional articles were identified from key references. Various public health websites were also explored. Most evidence was level II or III.

MAIN MESSAGE

Primary care physicians must always consider the risk of rabies when treating patients who have had animal-to-human exposures (eg, bite, scratch), and if indicated, postexposure prophylaxis must be administered as soon as possible because the infection is fatal once clinical symptoms develop.

CONCLUSION

Human cases of rabies are almost entirely preventable if suspected exposures are identified and managed promptly and properly. Primary care physicians must continue to work together with local public health officials in order to minimize the threat of this deadly virus.