Collaboration between primary care physicians (PCPs) and nephrologists in the care of patients with chronic kidney disease (CKD) is widely advocated, but how do these clinicians prefer to collaborate? That was the focus of recent research on CKD care (Diamantidis CJ et al. Primary Care-Specialist Collaboration in the Care of Patients with Chronic Kidney Disease. Clin J Am Soc Nephrol, February 2011).
“We were able to highlight how primary care providers and nephrologists differ on certain aspects of the care of patients with chronic kidney disease,” said first author Clarissa Jonas Diamantidis, MD, of the University of Maryland Medical Systems. “We were also able to identify potential barriers to collaboration among primary care providers and nephrologists.”
Nephrologists versus PCPs
Communication between PCPs and specialists in the care of patients with chronic illnesses has been linked with improved clinical outcomes, but collaborative care models for CKD across the United States have been limited.
“There are examples of successful multidisciplinary CKD teams including PCPs, nephrologists, nurses, pharmacists, social workers, and dieticians, but we have a long way to go in the U.S. to develop and test these models of care and determine if they are cost-effective,” said Wendy St. Peter, PharmD, of the University of Minnesota and the U.S. Renal Data System & Chronic Disease Research Group.
To assess physicians’ desires to collaborate, their preferred content of collaboration, and their perceived barriers to collaboration, Dr. Diamantidis and her colleagues had 124 PCPs and 120 nephrologists fill out a questionnaire describing the care of a hypothetical patient with progressive CKD. The investigators found that most physicians (85 percent of PCPs and 94 percent of nephrologists) desired collaboration and preferred that PCPs play a significant ongoing role in care. The most frequently desired types of input from nephrologists in collaborative care were: 1) confirmation of PCPs’ appropriate clinical evaluation, 2) guidance regarding additional evaluation and testing, 3) medication regimen advice, and 4) nutritional advice.
Nephrologists were more likely than PCPs to report they had sufficient ancillary support for the care of their patients with CKD and that they felt the medical care they provide was helpful in slowing CKD disease progression. They also were less likely to perceive insurance as a barrier to nephrology referral. More than half of nephrologists felt that patients were referred too late, and nearly one-third felt patients seen in consultation were taking inappropriate medications.
Nephrologists were more likely than PCPs to prefer collaboration focusing on predialysis/renal replacement therapy preparation (73 percent versus 52 percent) and electrolyte management (81 percent versus 46 percent). PCPs were more likely to desire collaboration if the hypothetical patient had both diabetes and hypertension, rather than hypertension alone; if they believed the care they provide helps slow CKD disease progression; and if they did not perceive health insurance as a barrier to referral to a nephrologists.
Future directions
The study’s findings could have important clinical applications, as PCPs often misjudge the severity of CKD or refer patients to nephrologists so late that interventions to slow CKD progression or prepare patients for renal replacement cannot be implemented in a timely manner.
“As medical conditions become more complex and health care reform takes effect, primary care providers and specialists must work together more and more to provide optimal care to patients. Identifying physicians’ perspectives on how that care should be provided is the first step in a process that will ultimately lead to improved quality of care and patient outcomes,” said Diamantidis.
Others in the field say the research offers important information and should stimulate additional investigations.
“This study suggests that it would be worthwhile to develop and evaluate new multidisciplinary collaborative care models to optimize care in CKD patients,” said St. Peter. She added that addressing barriers to collaboration will also be important.
“The study provides some insights into the different perceptions between PCPs and nephrologists as to what the patient needs truly are, and how best to meet them. There is a need for us as health care providers not only to understand the information requirements of each other, but also to engage patients in what their expectations are,” said Adeera Levin, MD, FRCPC, a professor in the division of nephrology at the University of British Columbia, in Vancouver, Canada.
