- Patients with more serious forms of chronic kidney disease (CKD) benefit from a cooperative chronic disease management approach that integrates both primary care providers (PCPs) and nephrologists, according to a study published this month in BMC Nephrology. Collaboration across care settings was associated with better monitoring for co-morbidities and complications as well more appropriate prescribing of cardiac medications.
Twenty-six million Americans suffer from some form of chronic kidney disease, the study says, though the vast majority are in the earliest stages of the condition and can generally receive adequate monitoring and care from their PCPs alone.
For patients entering stages 3 and 4 of the disease, however, clinical guidelines suggest the addition of a nephrologist’s care to the patient regimen. But little research has been done on the efficacy of co-management for these patients, who tended to be old enough to quality for Medicare coverage.
“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, 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,” the study says.
To better understand the relationship between co-management and quality of care, the researchers from Harvard Medical School and Brigham and Women’s Hospital in Boston gathered EHR and claims data on more than 3100 patients with stage 3 or stage 4 renal disease.
Only eight percent of stage 3 patients were being co-managed by a PCP and nephrologist, though that number jumped to 50 percent of stage 4 patients.
Patients who were receiving co-management tended to be younger, male, and non-white, the study found. They were almost more likely to be suffering from additional chronic conditions such as diabetes and hypertension, and logged more PCP visits than their peers. Patients saw their PCPs four times per year, on average, and co-managed patients made an average of two visits to their nephrologists.
Those patients receiving care from a PCP and a specialist were more likely to receive serum eGFR and urine protein/albumin testing, which help to monitor the progression of chronic kidney disease. These patients were also more likely to undergo serum hemoglobin, serum calcium, and serum phosphorus testing to check for potential complications.
While 69 percent of patients utilizing primary care alone received an ACE/ARB prescription, 77 percent of co-managed patients were prescribed the medication, with the main difference being found in stage 3 patients.
Neither stage 3 nor stage 4 patients undergoing co-management experienced significant differences in blood pressure control. About a quarter of early-stage CKD patients have uncontrolled high blood pressure, which may contribute to the development of comorbidities and other complications.
The study also found that patients who visited their primary care providers less frequently were less likely to be referred to a nephrologist for more specialized care, “which may reflect competing demands during office visits,” the authors posit. PCPs should develop more standardized methods for referring patients to specialists, and may wish to employ emerging predictive analytics and risk stratification tools that flag patients most likely to benefit from additional care.
Primary care providers who are managing CKD patients on their own can bolster monitoring for complications and disease progression by ordering more appropriate tests, and may be able to leverage EHR technology to improve chronic disease management workflows.
“One successful approach is through point-of-care EHR alerts that remind the physician of the diagnosis and recommended management of stage 3 CKD,” the study says. “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. A study in one of our practices combined EHR alerts and population management to successfully improve PCP management of CKD."
Better communication between PCPs and specialists could also improve the quality of care for patients, and may be able to have an impact on hypertension control and cholesterol levels. “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,” the authors state.
“Ideally, we will develop EHR alerts that are sophisticated enough to track management over time and to consider previous medication regimens and drug allergies,” the study concludes. “Perhaps more importantly, we should routinely employ effective patient-centered interventions to improve medication adherence.”
“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.”