Impact of quality improvement initiatives to improve CKD referral patterns: a systematic review protocol.

INTRODUCTION: Chronic kidney disease (CKD) is a global-health problem. A significant proportion of referrals to nephrologists for CKD management are early and guideline-discordant, which may lead to an excess number of referrals and increased wait-times. Various initiatives have been tested to increase the proportion of guideline-concordant referrals and decrease wait times. This paper describes the protocol for a systematic review to study the impacts of quality improvement initiatives aimed at decreasing the number of non-guideline concordant referrals, increasing the number of guideline-concordant referrals and decreasing wait times for patients to access a nephrologist. METHODS AND ANALYSIS: We developed this protocol by using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Protocols (2015). We will search the following empirical electronic databases: MEDLINE, Embase, Cochrane Library, CINAHL, Web of Science, PsycINFO and grey literature for studies designed to improve guideline-concordant referrals or to reduce unnecessary referrals of patients with CKD from primary care to nephrology. Our search will include all studies published from database inception to April 2021 with no language restrictions. The studies will be limited to referrals for adult patients to nephrologists. Referrals of patients with CKD from non-nephrology specialists (eg, general internal medicine) will be excluded. ETHICS AND DISSEMINATION: Ethics approval will not be required, as we will analyse data from studies that have already been published and are publicly accessible. We will share our findings using traditional approaches, including scientific presentations, open access peer-reviewed platforms, and appropriate government and public health agencies. PROSPERO REGISTRATION NUMBER: CRD42021247756.

Salvage of Malfunctioning Peritoneal Dialysis Catheters: An Algorithm for Recanalization and Repositioning.

A peritoneal dialysis catheter salvage algorithm was developed and performed for 40 patients with documented catheter malfunction (obstruction and/or malposition) referred to the interventional radiology suite. This procedure utilized a metallic stiffener for repositioning and rotating dual guide wires for recanalization. A retrospective analysis of 35 cases of fluoroscopic manipulation showed that in 83% of the cases, the catheters were successfully repositioned and/or recanalized, and in 59%, they remained patent at 30 days. No major adverse events occurred. The results suggest that this algorithm is a safe and effective approach to salvage malfunctioning peritoneal dialysis catheters and that a trial of fluoroscopic salvage can be considered prior to surgical intervention.

Electronic Advice Request System for Nephrology in Alberta: Pilot Results and Implementation.

BACKGROUND: Residents of rural areas of Alberta face significant barriers regarding access to specialist care, resulting in delays in provision of optimal care. Electronic referral and consultation systems are promising tools for facilitating timely access to specialist care, especially for people living in rural locations. OBJECTIVE: To report our initial experience with the launch of an electronic advice request system for ambulatory kidney care in Alberta, Canada. METHODS: We analyzed electronic advice requests for nephrology services in Alberta after the system's pilot launch, from October 2016 to December 2017. Data for province-wide advice request utility by primary care providers (PCPs) were extracted from Alberta Netcare for analysis. RESULTS: The total number of electronic advice requests directed to nephrology was 118 (mean number of requests: 2 per week). Only 31 (26.3%) of the cases required a face-to-face clinic visit with a nephrologist. Most (87; 73.7%) cases were managed by PCPs with ongoing nephrologist support via the advice request tool. Typical nephrologist response time was 5.7 ± 0.6 (mean ± SEM) days. CONCLUSION: These preliminary data suggest that the electronic advice request program has potential to enhance timely access to specialist kidney care and minimize unnecessary nephrologist visits while reducing response time. Broad implementation of this system may have a substantial positive impact on health outcomes and improve cost-effectiveness for nephrology care in the long term, particularly in rural communities of Alberta.

CONTEXTE: Les résidents des zones rurales de l'Alberta se heurtent à des obstacles importants en ce qui concerne l'accès aux soins spécialisés, ce qui entraîne des retards dans la fourniture de soins adéquats. Les systèmes électroniques de référence et de consultation sont des outils prometteurs qui peuvent faciliter un accès rapide à des soins spécialisés, en particulier pour les personnes résidant en milieu rural. OBJECTIF: Présenter notre première expérience avec le lancement d'un système de demande de consultation électronique en soins rénaux ambulatoires en Alberta, Canada. MÉTHODOLOGIE: Nous avons analysé les demandes de consultation électroniques pour des services de néphrologie en Alberta, entre octobre 2016 et décembre 2017, après le lancement pilote du système. Les données sur la pertinence des demandes de consultation à l'échelle provinciale, et selon les fournisseurs de soins primaires, ont été extraites du registre Alberta Netcare pour fins d'analyze. RÉSULTATS: Le nombre total de consultations électroniques adressées en néphrologie était de 118 (moyenne de 2 demandes/semaine), et 31 cas seulement (26,3%) ont nécessité une visite en clinique avec un néphrologue. La majorité des cas (87), soit 73,7%, a été prise en charge par des fournisseurs de soins primaires qui bénéficiaient du soutien permanent d'un néphrologue par l'entremise de l'outil électronique. Le temps de réponse moyen des néphrologues était de 5,7 ± 0,6 jour (moyenne ± SEM). CONCLUSION: Ces données préliminaires suggèrent que le program de demande de consultation électronique pourrait faciliter l'accès rapide à des soins par un néphrologue et minimiser les visites inutiles en clinique, tout en réduisant le temps de réponse. La mise en œuvre à grande échelle de ce système pourrait avoir une incidence très positive sur les résultats de santé et améliorer la rentabilité des soins en néphrologie à long terme, en particulier dans les communautés rurales de l'Alberta.

Quality of care for First Nations and non-First Nations People with diabetes.

BACKGROUND AND OBJECTIVES: Compared with non-First Nations, First Nations People with diabetes experience higher rates of kidney failure and death, which may be related to disparities in care. This study examined First Nations and non-First Nations People with diabetes for differences in quality indicators and their association with kidney failure and death. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Adults with diabetes and an outpatient creatinine in Alberta from 2005 to 2008 were identified. Logistic regression was used to determine the likelihood of process of care indicators (measurement of urine albumin/creatinine ratio [ACR], LDL, and hemoglobin A1C [A1C]) and surrogate outcome indicators (achievement of LDL and A1C targets). Cox regression was used to determine the association between lack of achievement of indicator targets and each of kidney failure and death. RESULTS: This study identified 140,709 non-First Nations and 6574 First Nations People with diabetes. There was a significant interaction between First Nations status and CKD for the outcomes (P<0.01); therefore, results are stratified by CKD. Among participants without CKD, First Nations People were less likely to receive process of care indicators and achieve target A1C compared with non-First Nations People. For those with CKD, First Nations People were as likely to receive these indicators (other than LDL) and achieve LDL and A1C targets. Lack of LDL and A1C assessment and achievement of targets were associated with increased risk of kidney failure and death similarly for both groups. CONCLUSIONS: Compared with non-First Nations, First Nations People with diabetes but without CKD experience disparities in assessment of quality indicators and achievement of A1C target.

Ascorbic acid for anemia management in hemodialysis patients: a systematic review and meta-analysis.

BACKGROUND: Ascorbic acid is believed to improve anemia in patients with end-stage renal disease, but its overall effectiveness is unclear. STUDY DESIGN: Systematic review and meta-analysis. SETTING & POPULATION: Adult hemodialysis patients. SELECTION CRITERIA FOR STUDIES: Randomized clinical trials of ascorbic acid use in addition to standard anemia management. INTERVENTION: Ascorbic acid. OUTCOMES: Weighted mean difference (WMD) for change in hemoglobin level, recombinant human erythropoietin (rHuEPO) dose, transferrin saturation and ferritin level and adverse events. RESULTS: Of 157 potentially relevant studies, 6 studies (n = 326 patients) met the inclusion criteria. Combining the 3 randomized clinical trials involving patients with baseline hemoglobin levels <11 g/dL, change in hemoglobin level was greater for ascorbic acid use compared with standard care (WMD, 0.9 g/dL; 95% CI, 0.5-1.2 g/dL). Compared with standard care, ascorbic acid use also was associated with a statistically significant decrease in rHuEPO dose (WMD, -17.1 U/kg/wk; 95% CI, -26.0 to -8.2 U/kg/wk) and improvement in transferrin saturation (WMD, 7.9%; 95% CI, 5.2-10.5%), with no change in ferritin concentration. Adverse events had questionable relevance to ascorbic acid use; no study reported oxalate levels or occurrence of oxalosis. LIMITATIONS: Small number of studies, heterogeneity between study populations, and study durations were short. Adverse events were poorly reported. CONCLUSIONS: Although the studies are limited by small numbers of subjects, short durations of follow-up, and variable quality, these results suggest that compared with standard care, ascorbic acid use may result in an increase in hemoglobin concentration and transferrin saturation and decrease in rHuEPO requirements. Longer term studies are required to confirm these results, provide information about adverse events, and determine whether these changes translate into improved patient outcomes and cost-effectiveness.