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Timely Referral and Co-Management of CKD Patients. Christopher Keller, MD Director of Clinical Operations Boise Kidney and Hypertension Institute RPA 2011 Annual Meeting Friday, March 18, 2011. Disclosure of Conflict of Interest. Timely Referral and Co-Management of CKD Patients.

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Timely referral and co management of ckd patients

Timely Referral and Co-Management of CKD Patients

Christopher Keller, MD

Director of Clinical Operations

Boise Kidney and Hypertension Institute

RPA 2011 Annual Meeting

Friday, March 18, 2011



Timely referral and co management of ckd patients1

Timely Referral and Co-Management of CKD Patients

Christopher Keller, MD

Director of Clinical Operations

Boise Kidney and Hypertension Institute

RPA 2011 Annual Meeting

Friday, March 18, 2011


Complexity

Anemia/

Bone

Dialysis


What are the issues
What are the issues?

  • Primary care providers (PCPs) often defer referrals until very advanced stages of CKD

    • 25-50% of all ESRD patients never saw a nephrologist until 3 months or less before onset of dialysis

    • Reasons for not referring: advanced age, comorbidities, and perceived patient nonadherence to therapy

Fischer MJ et al., Am J Nephrol 2011;33:60-69

Navaneethan et al., Clin Nephrol 2010;73:260-267


What are the issues1
What are the issues?

  • Nephrologists are spending more time focused on CKD progression and less time on non-nephrology concerns

    • The use of a multidisciplinary team (MDT) to manage stage 3-4 CKD patients may slow progression of CKD and may improve outcomes at the start of dialysis

Diamantidis CJ et al., Clin J Am Soc Nephrol 2011;6:334-343

Bayliss EA et al., Clin J Am Soc Nephrol 2011;6: April Epub


Slowing ckd progression with an mdt
Slowing CKD progression with an MDT

Bayliss EA et al., Clin J Am Soc Nephrol 2011;6: April Epub


Mortality benefit with an MDT

Kaplan-Meyer survival after starting dialysis therapy

Curtis et al. Nephrol Dial Transplant 2005;20:147


Open the black box
Open the black box…

  • PCPs must play a critical role in the multidisciplinary team

  • RPA ToolKit website: http://www.renalmd.org/toolkit-form/

Diamantidis CJ et al., Clin J Am Soc Nephrol 2011;6:334-343


How do we involve primary providers
How do we involve primary providers?

  • Step 1: Identify your goals for co-management

    • Preferences for timing of referrals

  • Step 2: Open communication lines with primary providers

    • Ask them directly about their co-management interests

    • Let them know that you are willing to answer questions

Tonelli M et al., Ann Intern Med 2011;154:12-21


How do we involve primary providers1
How do we involve primary providers?

  • Step 3: Communicate regularly with primary providers

    • Ensure timely, effective communication with the PCPs every visit

    • Track referrals and identify providers that do not refer early; devote resources for education

    • Electronic record systems and note templates make it easier



Conclusions
Conclusions

  • The complexity and breath of nephrology management has been a barrier to PCP communication

  • Multidisciplinary care of advanced CKD patients may slow CKD progression and reduce mortality in CKD patients

  • Communication with PCPs is required to:

    • Optimize early referrals

    • Permit nephrologists more time and energy to focus on prevention of ESRD



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