Background
Methods
Study site and systems
Estimated GFR (eGFR) reporting by laboratory
Qualitative methods
Recruitment and study participants
Data collection and analysis
Results
PCP | Allied* | Totals | |
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(n = 13) | (n = 6) | (n = 19) | |
Provider Type
| 8 IM; 5 FP | 2 IM; 4 FP | 10 IM; 9 FP |
Yrs at KP**
| Range 2–30; | Range 11–22; | |
Ave: 16.3 | Ave: 18.5 | ||
Clinical Allocations
| 4 FTE; 9 PTE | 4 FTE; 2 PTE | |
Panel Size
| Range 700–2044; | Range 1000–1405; | |
Ave: 1251 | Ave: 1176*** | ||
Other Roles****
| 9 | 2 |
Clinician use of eGFR: before and after automated reporting
Use of eGFR Value Before Automatic Reporting | ||||
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Common Theme and Key Findings | PCP | Allied | Totals | Illustrative Quotes |
(n = 13) | (n = 6) | (n = 19) | ||
Provider Calculated eGFR Prior
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I would sometimes calculate it [eGFR]to see, but it wasn’t common. And that was generally if their creatinine wasn’t normal, just so I’d have a better idea of how bad their GFR was. But I wouldn’t if they were older and they had a normal creatinine. – IM PCP | |||
· sometimes to occasionally | 6 | 0 | 6 | |
· rarely to never | 7 | 6 | 13 |
No, I never calculated it [GFR]… I would just look at their creatinines and if they were elevated…. – FM NP |
Provider Primarily Utilized Creatinine
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· yes | 13 | 6 | 19 |
… all I ever did [prior] was keep track of patients’ creatinines. – FM PCP |
Use of eGFR Value After Automatic Reporting
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Common Theme and Key Findings
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PCP
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Allied
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Totals
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Illustrative Quotes
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(n = 13)
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(n = 6)
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(n = 19)
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Changed Overall Approach to CKD Management
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There’s a number of folks [with Stage] 2 CKD …, I feel like it helps me manage them a lot better. –FM NP | |||
· yes | 8 | 4 | 12 |
Definitely it has shifted my clinical practice…I think I run less and less into trouble ordering certain medications. – IM PCP |
· no / not much | 5 | 2 | 7 |
It hasn’t necessarily changed my approach… It may have just labeled them as having now another problem. – IM PCP |
Utilization of eGFR & Creatinine Values in Decision-making
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· uses both | 11 | 4 | 15 |
Now I look at the trends in both creatinine and their GFR. And I do update in the patient’s problem list… - IM PCP |
· uses eGFR more often | 2 | 1 | 3 |
I do look at the trend of GFR, and that helps me, first of all, in updating the diagnosis or putting the diagnosis in the problem list… It’s very helpful. So, yeah, I do look [eGFR] up a lot. – IM PCP |
· uses creatinine more often | 0 | 1 | 1 |
Benefits and challenges of automated eGFR
Benefits | |
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Common Theme and Key Findings | Illustrative Quotes |
Time Savings
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I thought it was great [to have it automatically reported], because I didn’t have to try to manually calculate it. Prior I had been using kind of just ballpark numbers to try to guesstimate when I thought somebody’s renal function was starting to decline and if I needed to adjust medication. So, it was challenging because it added work to my day to have to manually do that or try to assess that… So it has made life easier for me to have it calculated. – FM PCP |
· automatic calculation and reporting makes approach and work to CKD management more streamlined | |
· easier to have eGFR calculated for provider - saves valuable clinic time to not calculate equation on own when they need it | |
I think it’s a good tool. So the fewer steps that we have to do to get to the right answer, and the right thing to do, the better it is. I think the automatic calculator is quicker and better at math than I am, and more reliable. And so, it takes away some of the potential for error that I might have introduced by manually doing the calculations myself. – IM PCP | |
Grateful for the Information
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Well, what it did was show that there were a lot of people with worse renal function than we had appreciated previously based just on creatinine. … we started looking at treatment of Stage 3′s, …trying to put [them] on ACE inhibitors. It wasn’t a usual practice until that [automatic reporting] happened. And without [automatic reporting], it would be very difficult to do. – IM PCP |
· providers wish they had the automatic eGFR value prior | |
· providers feel the missed opportunity to help some patients by not having the automatic value previously | |
· believe it to be a good clinical tool |
The ongoing reaction I’ve had [to the automatic reporting], is wishing I had known this a longtime ago. … It just makes me think of all the stuff I wasn’t doing or keeping track of before. - FM NP |
· helpful to have a more precise picture of renal health and CKD staging than just creatinine could provide | |
I find it is really helpful. I think it’s a useful tool to use as a screen. And I really think it’s an important item to have on the problem list so that you pay attention when you’re prescribing… it becomes part of your decision making if you’re going to moderate dosing of medication. – IM PCP | |
Increased Awareness
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It helps me when I review the charts for certain treatments or just to get to know the patient. It makes me aware that I can’t order certain medications. And it definitely makes me aware that I should check it at regular intervals to make sure I don’t miss when it starts trending down. – IM PCP |
· created more awareness of and attention to tracking CKD in general | |
· now know about and can manage all the patients provider did not know about before automatic reporting began that have a “normal or slightly abnormal” creatinine and an abnormal eGFR |
Well, it’s made more awareness of chronic kidney disease. It’s sort of opened up a whole new [population] of chronic kidney disease patients. And it’s probably a more sensitive number to follow, rather than the creatinines…I can have a creatinine of 1.4 in one person, with a normal GFR, and a creatinine of .9 with an abnormal GFR - the GFR is simpler to pull. So ultimately I like it better. - FM PCP |
· identified a pool of patients on providers’ panel with CKD status much worse than the creatinine value alone was indicating – would not have “known” about these patients or referred on to Nephrology without automatic reporting | |
Some of the patients who had a mildly abnormal creatinine I’m now finding have a much more reduced GFR, and that puts them in a higher stage of chronic kidney disease. And I am picking up a few of those that I wouldn’t have known before and then referring them on…It’s just that it alerts me to the fact that their kidney disease is worse than I might have suspected just from the level of creatinine. – IM PCP | |
Improve Patient Care and Management
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It’s very much helped with the care of patients. I feel like I know what’s going on all the time now and I do a better job…I feel like all the people I didn’t, you know, do right by before - and that kind of kills me - I feel like I give them good care finally. –FM NP |
· overall provide better patient care by having the automatic eGFR value | |
· improves the ability of providers to assess and act on a patient’s renal health and functioning earlier or to determine appropriate referral to Nephrology at earlier time points |
If there’s a low GFR but their creatinine is normal, I might have ignored that before…[because] I thought [their renal function] was normal. So that’s the major difference …because before if the creatinine was one, I might not have ordered it for another year. Whereas now, if it reflects a low GFR I might order it more often, or start adjusting the medicines. So I’m definitely ordering more tests. - FM PCP |
· greatly helps in medication management efforts, including determining both the appropriate type and dosage of medication · having the more sensitive value of the eGFR, along with creatinine, helps give gradation and refinement to patients’ renal health – helps provider determine “just how bad” a patient may or may not be |
And the one thing that I feel it does do, if a patient goes into a hospital, having GFR value [CKD stage] on the problem list will protect him from somebody starting a dangerous medication and monitor it more closely… I want to optimize the person’s blood pressure. I want to optimize their sugar control. I want to be careful with what medications I’m using… monitoring them with the GFR has more meaning than monitoring them with the creatinine. So it’s nice to have it more available now. - IM PCP |
· helps provider manage the Medicare refresh diagnosis process related to CKD status | |
Challenges
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Common Theme and Key Findings
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Illustrative Quotes
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Patient Confusion / Fear
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Some patients were shocked – they were dismayed. They wanted to talk to me. I had some people who just couldn’t understand, asking ‘What’s wrong with my kidneys?’… FM NP
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· initially caused some otherwise healthy patients concern and upset regarding “suddenly” having a CKD diagnosis | |
So, I think it caused distress and some fear because I never told them anything was wrong before, or I was waiting until their creatinine got high before I figured it out. - FM PCP | |
· initially caused some otherwise healthy patients undue fear and stress regarding their kidney health and future possibility of dialysis |
It’s still a bit of an issue where there is that disconnect between some of the older patients who have a normal creatinine but their GFR is in the chronic kidney disease range. So it generated for some patients’ questions, concern, alarm that I think wasn’t really necessary. – IM PCP |
Increase Provider Workload
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So basically, there might have been fifty or a hundred people who I had considered normal, who all of a sudden had CKD3, by the GFR definition. So really, it’s more work, but if that’s the definition, then that’s the definition, and it’s real. So I’ve made mechanisms to deal with it. – FM PCP |
· initial reporting created a “new”, “unknown”, and “larger” pool of patients in Stage 3 that now needed outreach and follow-up | |
· initially created a “thinking” burden when trying to determine the correct e GFR value on lab report – (both African American and Caucasian values reported) |
I think the automatic reporting is an absolutely great idea. But, the actuality is we’ve got some problems with how the computer reports it…I should not have to read every time the African and non-African American values when the computer could somehow designate that. If we have race in our computer, it should be automatically reported as the [correct] GFR and the computer should be estimating for the race. I shouldn’t have to be wasting one second of time thinking about that…It hasn’t created clinical harm, but it’s just extra thought and extra work for me. – IM PCP |
· generated more follow up and tracking work for providers – another condition to now follow and manage | |
· extra time and workload for provider to create their own systems and processes for tracking, monitoring, and following up on patients eGFR values and renal health | |
Initially I felt there was a little confusion to patients around giving the limits of normal GFR, so that the patient who was older could have a normal creatinine but an abnormal GFR, and the lab result would indicate chronic kidney disease. And it just added a little extra problem of something you either had to explain to the patient, or that they would ask questions about…I would usually then end up having to generate some sort of a letter explaining it, rather than just sending out a copy of the lab report, which made more work for me. – IM PCP | |
· extra time and workload for provider to address patient fears and concerns regarding meaning of eGFR value and CKD stage/status (phone calls, creating patient letters) |
Changes in work practices related to CKD management
Common Theme and Key Findings | PCP | Allied | Totals | Illustrative Quotes |
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(n = 13) | (n = 6) | (n = 19) | ||
Patient Communication and Activation Activities
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If it is under 60, I tell the patient about what’s going on. I spend time trying to educate the patient on that and things to avoid to stay as healthy as possible…I do talk to and counsel people more now than I ever have before, on the NSAID usage or abuse. And it may correlate in terms of timing with that [automatic reporting]. – IM PA
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· increased counseling / education discussions with patients about GFR value, kidney health, and CKD management | 6 (yes) | 4 (yes) | 10 | |
7 (no) | 2 (no) | 9 | ||
I use the eGFR information quite a bit… have a conversation when people need more information about protecting their kidneys if they get down to a GFR below 60. So, if their cholesterol is high, give them information about their cholesterol. If their GFR is low, try to get them to do some things to protect their kidneys, etc. – FP PA
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I am more aggressive about counseling for prevention of kidney disease, now… I start talking with them about making sure they’re getting plenty of water, avoiding caffeine, making sure their blood pressure is in control, making sure they’re not on high protein diets that are more challenging for the kidney to filter, etc. … and so just a lot of a more aggressive lifestyle counseling for things that may maintain or maybe even improve kidney function. – FP PCP
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It depends on the patient and what I’m explaining, whether or not I go into it with them. Obviously, if they ask me, then I tell them. Generally I don’t bring it up – it’s more how I practice what I’m doing. – IM PA
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· created specialized letters and phone talking points for explaining eGFR results and follow up activities to patients | 9 (yes) | 4 (yes) | 13 |
I send the patient a letter, using a dot phrase which described the patient’s kidney function – explains that if it’s a little bit off, it could be for many reasons, and that often it is age and kidneys, but that at this point it’s not concerning and we want to re-check in 3 months. – FP NP
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4 (no) | 2 (no) | 6 | ||
It does generate the need for additional information. I have dot phrases that I use to explain GFR, just to let them know the filtration rate and what that means. I have dot phrases that explain where they can get more information from the [National Kidney Foundation]– FP PCP
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So I have devised my own method that seems rational to me…I have a dot phrase for when the creatinine is normal, and the GFR is low and it says, ‘Your creatinine is normal but your GFR is low, sometimes this can be due to diabetes or high blood pressure, and a lot of times in three months it changes back to normal, so let’s check it in 3 months…’ etc. – IM PCP
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Overall Referral Patterns to Nephrology
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Yes, I am possibly referring more [to Nephrology]…I would have to say about 5 percent more, and chart review is my first request. – IM PA
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· subtle increase (approx. 1 to 2 month) | 8 | 6 | 14 | |
It’s probably a subtle increase, because the information is so clearly in your face, as a clinician you can just see it. It would be hard to ignore, or hard to get distracted and not pick it up, the way it’s reported. – NP IM
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I think it has increased the number…probably once a month I’m referring someone - maybe once or twice a month - to the nephrologist…for a face to face or chart review, it varies. –FP PCP
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It has some because… once it gets down towards thirty, then I’ll refer them to Nephrology to take a look at it. And sometimes if I’m really not sure and it’s getting closer and I’m worried about something or other, I’ll have the nephrologist do a chart review. – IM PCP
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· no perceived increase in referrals | 4 | 0 | 4 |
It’s not had much impact on my referral to nephrology because usually I don’t refer unless it gets much lower than that. So for the mildly decreased GFR’s of 45 to 60 range, I’m still managing it. – FP PCP
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No, I don’t refer more… I just treat them. They only ones that get a chart review are the Stage Fours. And they’re not that many of those. – IM PCP
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· believe referrals have decreased | 1 | 0 | 1 |
I’ve probably cut down the number of referrals to Nephrology… I don’t know that I referred a lot before the change, but I would say in general probably it’s reduced the amount of referrals because I can monitor more, and try to help prevent them from progressing. I can do interventions earlier. – FP PCP
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Typical GFR Referral “Cut-off” Values
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Well, it’s probably when it gets down closer to 40 or below I’m more likely to do a referral to Nephrology and specify a chart review. …If it’s hovering around 60, or if it’s in the mid-fifties, I don’t feel so compelled to do anything about it, right then, except to make sure that the patient gets rechecked again in 6 months, or something. – IM NP
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· eGFR value low 40’s to 40 | 1 | 4 | 5 | |
I believe it’s 40 or 45, is the cutoff point between seeing the Nephrologist or not… if it’s in that 40 range or so, then usually I go ahead and refer at some point. Usually I follow them for at least a few months and have done the other lab work and ultrasound within that timeframe. – FP PCP
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· eGFR value 35 or less | 4 | 0 | 4 |
Well, the nephrologists have said [to refer for] a GFR for less than 35 …So I do. Period. But I have patients who don’t quite make that….clearly, somebody who has a big jump, without a reason for it, [needs] to have a conversation with the nephrologist, or a referral to the nephrologist. - FP PCP
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If in the CKD3 range then just continuing the counseling, lifestyle modifications, and monitoring. And then if it’s dipping into the CKD4 where they’re down in that like 15 to 30 range, I’m thinking renal referral [to Nephrology]. – FP PCP
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· eGFR value 15 to 30 | 4 | 0 | 4 |
When they get down to the twenties or especially below, then I usually will refer. Or if they may be Stage 3, but for some reason they seem to be dropping rapidly… Although, usually I’ll work those up first myself. I’ll get an ultrasound and recheck them, and maybe take them off some possible medications and then see what happens. I do all that first, and only if nothing budges …, I usually then ask for a referral. – IM PCP
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· Base it on creatinine not eGFR | 0 | 1 | 1 |
So I don’t refer or ask for chart review from nephrology when eGFR is under 60 though…As far as referral, the threshold is probably closer to 2 on a creatinine. So I use creatinine in that respect. – IM PA
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· did not offer typical cut-off value (based on trends over time) | 4 | 1 | 5 |
I probably don’t have a set number, because it would depend on the whole picture of the patient I want to know if this is a new occurrence or if this is a trend. Is this particular patient a diabetic? If it’s an acute new problem, I would treat it differently than if it’s a chronic ongoing problem. – FP PA
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Well, rather than a number, it is a trend… for a patient I’d be looking back and if he or she hadn’t changed much in a year, I wouldn’t be referring.–IM PCP
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Overall Referral Patterns to Kidney Class
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I definitely refer more to the class…I like them to go to the kidney class to learn more about how to protect their kidneys. – FP PA
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· refer more to class now | 1 | 1 | 2 | |
· refer infrequently to occasionally | 4 | 3 | 7 |
When people are anxious, I will refer to the class for reassurance purposes and education. But I don’t send a high percentage of patients to that class, and I don’t take advantage of that resource as often as I could. – IM PA
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I’m aware of it, and I might have referred one person in the past couple of years but usually it’s for the lower GFR’s – like a low 30 – to have them look at their diet and things. But so far I haven’t used that class that much. – FP PCP
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· never refers to class | 2 | 0 | 2 |
I’ve never referred to the kidney class myself. I have the impression that patients who go to kidney class are really the ones who already saw the nephrologist, or if they [Nephrology] advise me in a chart [consult]… - IM PCP
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· no awareness of class/did not mention | 6 | 2 | 8 |
I didn’t even know about it [kidney class]… there you go, I learned something. – IM PCP
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Suggestions to improve utilization of automated eGFR reporting in clinical practice
Common Theme and Key Findings | Illustrative Quotes |
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Ongoing Provider Education
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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
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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
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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
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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
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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 |