Effect of primary care physicians' use of estimated glomerular filtration rate on the timing of their subspecialty referral decisions

Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
BMC Nephrology (Impact Factor: 1.69). 01/2011; 12(1):1. DOI: 10.1186/1471-2369-12-1
Source: PubMed


Primary care providers' suboptimal recognition of the severity of chronic kidney disease (CKD) may contribute to untimely referrals of patients with CKD to subspecialty care. It is unknown whether U.S. primary care physicians' use of estimated glomerular filtration rate (eGFR) rather than serum creatinine to estimate CKD severity could improve the timeliness of their subspecialty referral decisions.
We conducted a cross-sectional study of 154 United States primary care physicians to assess the effect of use of eGFR (versus creatinine) on the timing of their subspecialty referrals. Primary care physicians completed a questionnaire featuring questions regarding a hypothetical White or African American patient with progressing CKD. We asked primary care physicians to identify the serum creatinine and eGFR levels at which they would recommend patients like the hypothetical patient be referred for subspecialty evaluation. We assessed significant improvement in the timing [from eGFR < 30 to ≥ 30 mL/min/1.73m(2)) of their recommended referrals based on their use of creatinine versus eGFR.
Primary care physicians recommended subspecialty referrals later (CKD more advanced) when using creatinine versus eGFR to assess kidney function [median eGFR 32 versus 55 mL/min/1.73m(2), p < 0.001]. Forty percent of primary care physicians significantly improved the timing of their referrals when basing their recommendations on eGFR. Improved timing occurred more frequently among primary care physicians practicing in academic (versus non-academic) practices or presented with White (versus African American) hypothetical patients [adjusted percentage(95% CI): 70% (45-87) versus 37% (reference) and 57% (39-73) versus 25% (reference), respectively, both p ≤ 0.01).
Primary care physicians recommended subspecialty referrals earlier when using eGFR (versus creatinine) to assess kidney function. Enhanced use of eGFR by primary care physicians' could lead to more timely subspecialty care and improved clinical outcomes for patients with CKD.

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Available from: Bernard G Jaar, Oct 09, 2015
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    • "Respondents were more likely to be internists and had graduated medical school more recently, characteristics that may suggest greater familiarity with CKD guidelines [13,16,42,56]. Indeed, self-reported guideline familiarity was modestly higher than in prior PCP survey studies [12,15,16], although it remained less than 50%. Second, the majority of targeted PCPs never opened a study email. "
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    ABSTRACT: Most non-dialysis dependent chronic kidney disease (CKD) patients are cared for by their primary care physicians (PCPs). Studies suggest many CKD patients receive suboptimal care. Recently, CKD clinical practice guidelines were updated with additional emphasis on albuminuria. We performed an internet-based, cross-sectional survey of active PCPs in the United States using the American Medical Association Physician Masterfile. We explored CKD guideline familiarity, self-reported practice behaviors, and attitudinal and external barriers to implementing guideline recommendations, including albuminuria testing. Of 12,034 PCPs targeted, 848 opened a study email, 165 (19.5%) responded. Most respondents (88%) spent >=50% of their time in clinical care. Respondents were generally in private practice (46%). Most PCPs (96%) felt that eGFR values were helpful. Approximately, 75% and 91% of PCPs reported testing for albuminuria in non-diabetic hypertensive patients with an eGFR > 60 ml/min/1.73 m2 and < 60 ml/min/1.73 m2, respectively. Barriers to albuminuria testing included a lack of effect on management, limited time, and the perceived absence of guidelines recommending testing. While PCPs expressed high levels of agreement with the definition of CKD, 30% were concerned with overdiagnosis in older adults with an eGFR in the CKD stage 3a range. Most PCPs felt that angiotensin converting enzyme inhibitor (ACEi)/ angiotensin II receptor blockers (ARBs) improved outcomes in CKD, though agreement was lower with severe vs. moderate albuminuria (78% vs. 85%, respectively, p = 0.03). Many PCPs (51%) reported being unfamiliar with CKD guidelines, but were receptive to systematic interventions to improve their CKD care. PCPs generally agree with CKD clinical practice guidelines regarding CKD definition and albuminuria testing. However, future interventions are necessary to improve PCPs' familiarity with CKD guidelines, overcome barriers to albuminuria testing and, assist PCPs in targeting ACEi/ARBs to the patients most likely to benefit.
    BMC Nephrology 04/2014; 15(1):64. DOI:10.1186/1471-2369-15-64 · 1.69 Impact Factor
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    • "The present recommendation is that GFR should be automatically reported using the CKD-EPI or MDRD equation whenever a creatinine measurement is ordered [1]. Primary care physicians recommended subspecialty referrals earlier when using eGFR versus creatinine for assessment of kidney function, thus improving clinical outcomes for patients with CKD [37] [38]. It is therefore of the utmost importance that available methods for measurement of creatinine be reliable, allowing correct identification of kidney disease. "
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    ABSTRACT: Objectives: The aim of this paper was to compare the agreement between creatinine measured by Jaffe and enzymatic methods and their putative influence on eGFR as calculated by the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equation in healthy and diabetic individuals. Design and methods: Cross-sectional study conducted in 123 adult southern Brazilians with GFR>60 mL/min/1.73 m² (53 patients with type 2 diabetes, 70 healthy volunteers). Mean age was 49±16 years (range of 19-86). Most were female (55%) and white (83%). Creatinine was measured by a traceable Jaffe method (Modular P, Roche Diagnostic) and by an enzymatic method (CREA plus, Roche/Hitachi 917). GFR was measured by the ⁵¹Cr-EDTA single-injection method. Results: Serum creatinine measured by the Jaffe and enzymatic methods was similar in healthy subjects (0.79±0.16 vs. 0.79±0.15 mg/dL, respectively, P=0.76), and diabetic patients (0.96±0.22 vs. 0.92±0.29 mg/dL, respectively, P=0.17). However, the correlation between the two methods was higher in the healthy group (r=0.90 vs. 0.76, P<0.001). The difference between Jaffe creatinine and enzymatic creatinine was <10% in 63% of cases in the healthy group and 40% of cases in the diabetes group (P=0.018). In the subset of patients with diabetes, eGFR based on enzymatic assay results showed better agreement with measured GFR than did eGFR based on Jaffe results. Conclusion: Jaffe and enzymatic creatinine methods show adequate agreement in healthy subjects, but in the presence of diabetes, the enzymatic method performed slightly better.
    Clinical biochemistry 06/2013; 46(15). DOI:10.1016/j.clinbiochem.2013.05.067 · 2.28 Impact Factor
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    ABSTRACT: outcomes and provide some insight into PCP management of CKD. Using the Cardiovascular Health Study, Dalrymple and colleagues compare the overall risk and risk factors of ESRD, cardiovascular death, and non-cardiovascular death among older (mean age of 75 years) community-dwelling adults with moderate CKD [median estimated glomerular filtration rate (eGFR) of 53 ml/min/1.73 m²]. They corroborate previous evidence that risk of death is much more likely than progression to ESRD in older adults 21 and highlight risk factors associated with all-cause mortality. Modifiable risk factors include body mass index
    Journal of General Internal Medicine 02/2011; 26(4):356-8. DOI:10.1007/s11606-011-1650-8 · 3.42 Impact Factor
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