Primary Care Physicians' Perceived Barriers to Nephrology Referral and Co-management of Patients with CKD: a Qualitative Study

Raquel C Greer; Yang Liu; Kerri Cavanaugh; Clarissa Jonas Diamantidis; Michelle M Estrella; C John Sperati; Sandeep Soman; Khaled Abdel-Kader; Varun Agrawal; Laura C Plantinga; Jane O Schell; James F Simon; Joseph A Vassalotti; Bernard G Jaar; Michael J Choi; National Kidney Foundation Education Committee

doi:10.1007/s11606-019-04975-y

Primary Care Physicians' Perceived Barriers to Nephrology Referral and Co-management of Patients with CKD: a Qualitative Study

J Gen Intern Med. 2019 Jul;34(7):1228-1235. doi: 10.1007/s11606-019-04975-y. Epub 2019 Apr 16.

Authors

Raquel C Greer^{1

2}, Yang Liu^{3

4}, Kerri Cavanaugh^{5

6}, Clarissa Jonas Diamantidis⁷, Michelle M Estrella⁸, C John Sperati⁹, Sandeep Soman¹⁰, Khaled Abdel-Kader^{5

6}, Varun Agrawal¹¹, Laura C Plantinga^{12

13}, Jane O Schell¹⁴, James F Simon¹⁵, Joseph A Vassalotti^{16

17}, Bernard G Jaar^{3

9

18

19}, Michael J Choi⁹; National Kidney Foundation Education Committee

Affiliations

¹ The Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, MD, USA. rgreer@jhmi.edu.
² Division of General Internal Medicine, Johns Hopkins University, 2024 E. Monument Street, Suite 2-600, Baltimore, MD, 21287, USA. rgreer@jhmi.edu.
³ The Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, MD, USA.
⁴ Johns Hopkins Medicine International, Johns Hopkins Medical Institutions, Baltimore, MD, 21287, USA.
⁵ Vanderbilt Center for Kidney Disease, Vanderbilt University Medical Center, Nashville, TN, USA.
⁶ The Division of Nephrology, Vanderbilt University Medical Center, Nashville, TN, USA.
⁷ Divisions of General Internal Medicine and Nephrology, Duke University School of Medicine, Durham, NC, USA.
⁸ Kidney Health Research Collaborative, Department of Medicine, Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco and San Francisco VA Health Care System, San Francisco, CA, USA.
⁹ Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA.
¹⁰ Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, MI, USA.
¹¹ Division of Nephrology and Hypertension, University of Vermont, Burlington, VT, USA.
¹² Department of Medicine, Emory University, Atlanta, GA, USA.
¹³ Department of Epidemiology, Emory University, Atlanta, GA, USA.
¹⁴ Section of Palliative Care and Medical Ethics, Renal-Electrolyte University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
¹⁵ Department of Nephrology and Hypertension, Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
¹⁶ National Kidney Foundation, New York, NY, USA.
¹⁷ Icahn School of Medicine at Mount Sinai, New York, NY, USA.
¹⁸ Nephrology Center of Maryland, Baltimore, MD, USA.
¹⁹ The Welch Center for Prevention, Epidemiology, and Clinical Research Institutions, Baltimore, MD, 21287, USA.

Abstract

Background: Effective co-management of patients with chronic kidney disease (CKD) between primary care physicians (PCPs) and nephrologists is increasingly recognized as a key strategy to ensure the delivery of efficient and high-quality CKD care. However, the co-management of patients with CKD remains suboptimal.

Objective: We aimed to identify PCPs' perceptions of key barriers and facilitators to effective co-management of patients with CKD at the PCP-nephrology interface.

Study design: Qualitative study SETTING AND PARTICIPANTS: Community-based PCPs in four US cities: Baltimore, MD; St. Louis, MO; Raleigh, NC; and San Francisco, CA APPROACH: We conducted four focus groups of PCPs. Two members of the research team coded transcribed audio-recorded interviews and identified major themes.

Key results: Most of the 32 PCPs (59% internists and 41% family physicians) had been in practice for > 10 years (97%), spent ≥ 80% of their time in clinical care (94%), and practiced in private (69%) or multispecialty group practice (16%) settings. PCPs most commonly identified barriers to effective co-management of patients with CKD focused on difficulty developing working partnerships with nephrologists, including (1) lack of timely adequate information exchange (e.g., consult note not received or CKD care plan unclear); (2) unclear roles and responsibilities between PCPs and nephrologists; and (3) limited access to nephrologists (e.g., unable to obtain timely consultations or easily contact nephrologists with concerns). PCPs expressed a desire for "better communication tools" (e.g., shared electronic medical record) and clear CKD care plans to facilitate improved PCP-nephrology collaboration.

Conclusions: Interventions facilitating timely adequate information exchange, clear delineation of roles and responsibilities between PCPs and nephrologists, and greater access to specialist advice may improve the co-management of patients with CKD.

Keywords: chronic kidney disease; co-management; nephrology; primary care; qualitative research.

Publication types

Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't

MeSH terms

Adult
Attitude of Health Personnel*
Disease Management
Female
Humans
Male
Middle Aged
Nephrology / methods
Nephrology / standards*
Physicians, Primary Care / psychology
Physicians, Primary Care / standards*
Qualitative Research*
Quality of Health Care / standards
Referral and Consultation / standards*
Renal Insufficiency, Chronic / epidemiology
Renal Insufficiency, Chronic / therapy*

Abstract

Publication types

MeSH terms

Grants and funding