Nephrology co-management versus primary care solo management for early chronic kidney disease: a retrospective cross-sectional analysis

Twenty-six million Americans have chronic kidney disease (CKD). Approximately 90 % of CKD patients are in an early stage of the disease and are typically cared for by primary care physicians (PCPs). U.S. and international guidelines recommend that physicians monitor for progression, monitor for complications, prescribe medications to delay progression, and focus on cardiovascular risk modification, all of which are within a PCP’s scope of practice [1]. Recent international guidelines, however,  recommend nephrology co-management for some patients with stage 3 CKD and all patients with stage 4 CKD, based on the assumption that co-management lessens complications, delays renal failure, and decreases mortality [2]. While nephrologist involvement is associated with decreased mortality for the small group of patients who progress to end stage renal disease and need renal replacement therapy [3, 4], we do not know whether co-management of a larger proportion of stage 3 patients and all stage 4 patients will improve quality of care. To assess the relationship between nephrology co-management and quality of care, we conducted a retrospective cross-sectional analysis of electronic health record (EHR) data for patients with stage 3 and 4 CKD, comparing co-managed patients to solo managed patients.

We found that only a small proportion (8 %) of stage 3 CKD patients and half of stage 4 CKD patients were co-managed by nephrology. Co-management was associated with socio-demographic differences, particularly in stage 3 CKD patients for whom co-management was associated with younger age, male gender and minority race/ethnicity. Co-management was associated with diabetes, hypertension, and more frequent PCP visits. After controlling for these potential confounders, co-management was associated with monitoring tests, both for progression and for complications. Co-management was associated with higher rates of ACE/ARB prescription in stage 3 CKD, but not in stage 4 CKD. Co-management was not associated with higher rates of cardiovascular risk modification through lipid monitoring or blood pressure control.

Our finding of a difference between the two groups for ACE/ARB prescription in stage 3, though not in stage 4, is in concert with another recently published study from the Chronic Renal Insuffiency Cohort (CRIC) [15]. One explanation for the higher impact of nephrology co-management in stage 3 CKD as compared to stage 4 CKD is low PCP recognition of CKD in stage 3. As we showed in a prior study, PCPs are more likely to diagnose CKD in patients with more advanced disease [16].

Co-management was associated with age, gender, and race/ethnicity. These associations align with patients who have higher muscle mass. This may indicate PCPs are still using serum creatinine levels rather than eGFR to judge severity of CKD in early disease. The only socio-demographic characteristic associated with nephrology referral in stage 4 CKD was younger age. PCPs were more likely to refer patients with diabetes in the stage 3 subgroup, which may reflect a higher rate of urine albumin screening and appropriate subsequent referral of albuminuric patients [16]. Patients who saw their PCP less often were less likely to be referred, which may reflect competing demands during office visits [17, 18]. We saw a similar dose–response relationship between the number of primary care visits and CKD documentation in our prior study [16] and the AVENIR study found a dose–response relationship between the number of nephrology visits and quality of care [19].

Other primary care CKD studies have revealed suboptimal urine protein testing, serum phosphorus testing, serum parathyroid hormone testing, prescription of ACE/ARB, and blood pressure control [16, 20‐22]. The AVENIR nephrology clinic study reported low rates, similar to ours, of urine protein testing at 50 % and ACE/ARB prescription at 67 %, in addition to a  BP control rate of 14 % (<130/80 mmHg), lower than ours [19]. One U.S. study designed to examine the impact of automated eGFR reporting also compared co-managed and solo managed patients (in stage 3b and 4, or eGFR 15–45 mL/min/1.73 m²). They found a significant difference in serum hemoglobin testing, serum phosphorus testing, and serum PTH testing, but neither urine protein testing (with a rate of <30 % overall) nor ACE/ARB prescribing (with a rate of <60 % overall) [23]. Ours is the first study to examine blood pressure outcomes in a similar manner.

There are several limitations to this study. There is a potential for type II error when we conclude that there is no difference in BP control between groups because co-managed patients may be sicker than solo managed patients. An analysis of anti-hypertensive regimens would help to elucidate any difference in management. There may be other patient level confounders for which we were unable to adjust. ACE/ARB prescriptions were assessed in all CKD patients, though these are only recommended for patients with either hypertension, diabetic kidney disease, or proteinuria. Our laboratory uses the MDRD equation to calculate eGFR without accounting for race. Generalizability is limited by the fact that the population is limited to one primary care network. We were unable to measure clinical outcomes such as progression to ESRD and mortality.

Our findings have implications for the following: 1) PCP solo management, 2)  nephrology co-management, and developing a systematic approach to  referral to nephrology.

First, PCPs should improve solo management in stage 3 CKD through monitoring for complications, monitoring for progression of disease, and intervening to delay progression. One successful approach is through point-of-care EHR alerts that remind the physician of the diagnosis and recommended management of stage 3 CKD. Such reminders have improved urine protein testing [24]. A second approach which addresses the lack of time in primary care visits is population management by a non-physician. Nurse-led population management has improved quality of care for diabetes and hypertension [25, 26]. A study in one of our practices combined EHR alerts and population management to successfully improve PCP management of CKD [27].

Second, quality of care for co-managed patients could improve as well. Co-management did not increase the likelihood of cardiovascular risk modification in stage 3 or stage 4 CKD. PCPs and nephrologists working together should be able to control patients’ blood pressure, yet we saw no difference in this measure between solo managed and co-managed patients. Both EHR alerts and population management are likely to be part of the answer [26, 28], but to date, there have been no successful systems-level interventions for uncontrolled blood pressure in a CKD population. Ideally, we will develop EHR alerts that are sophisticated enough to track management over time and to consider previous medication regimens and drug allergies [29, 30]. Perhaps more importantly, we should routinely employ effective patient-centered interventions to improve medication adherence [31, 32].

Third, and just as critical as the first (i.e. improving PCP solo management) and the second (i.e. improving co-management), is developing a systematic approach to referral. The current approach relies on  creatinine-based estimates of kidney function that do not accurately predict whether and when patients might progress [38, 39]; many patients do not progress.

That being said, two studies showed a slowing of progression in stage 3 CKD when nephrologists monitored patients electronically and gave advice to PCPs [40, 41]. At this point, we only have two studies to answer the important question of whether we can delay or prevent progression to ESRD through comanagement in stage 3 CKD. Further studies would be welcome. A potentially better approach would take into account the fact that nephrology referral has a mortality benefit when done 12 to 72 months before initiating dialysis [33‐37]. PCPs may be aided by risk estimation models such as one validated by Tangri and colleagues that incorporates additional metabolic parameters beyond serum creatinine in order to predict how likely a patient is to progress to renal failure within a five years [42]. Such prediction models could encourage PCPs to increase appropriate referrals to nephrology based on length of time before renal replacement therapy is needed, rather than stage-based referral.

In conclusion, early CKD is commonly managed in primary care, but patients who are co-managed by nephrology receive better monitoring for progression and complications. Improving the quality of PCP solo management will help to close this gap. In addition, about one-quarter of early CKD patients have uncontrolled blood pressure whether they have been referred to a nephrologist or not. We should study interventions to improve co-management of blood pressure and to decrease cardiovascular events. These interventions should include population management, EHR tools, and patient-centered interventions. Finally, we have sophisticated tools to risk-stratify patients with CKD and we must learn how best to employ these tools in primary care practices to systematize referral of high-risk patients.