Advanced CKD Care and Decision Making: Which Health Care Professionals Do Patients Rely on for CKD Treatment and Advice?

Tyler M Barrett; Jamie A Green; Raquel C Greer; Patti L Ephraim; Sarah Peskoe; Jane F Pendergast; Chelsie L Hauer; Tara S Strigo; Evan Norfolk; Ion Dan Bucaloiu; Clarissa J Diamantidis; Felicia F Hill-Briggs; Teri Browne; George L Jackson; L Ebony Boulware; PREPARE NOW study investigators

doi:10.1016/j.xkme.2020.05.008

Advanced CKD Care and Decision Making: Which Health Care Professionals Do Patients Rely on for CKD Treatment and Advice?

Kidney Med. 2020 Jun 15;2(5):532-542.e1. doi: 10.1016/j.xkme.2020.05.008. eCollection 2020 Sep-Oct.

Authors

Tyler M Barrett¹, Jamie A Green^{2

3}, Raquel C Greer^{4

5}, Patti L Ephraim^{4

6}, Sarah Peskoe⁷, Jane F Pendergast⁷, Chelsie L Hauer⁸, Tara S Strigo¹, Evan Norfolk², Ion Dan Bucaloiu⁹, Clarissa J Diamantidis^{1

10}, Felicia F Hill-Briggs^{4

5}, Teri Browne¹¹, George L Jackson^{1

12

13}, L Ebony Boulware¹; PREPARE NOW study investigators

Collaborators

PREPARE NOW study investigators:
L Ebony Boulware, Clarissa Diamantidis, Clare Il'Giovine, George Jackson, Jane Pendergast, Sarah Peskoe, Tara Strigo, Jon Billet, Jason Browne, Ion Bucaloiu, Charlotte Collins, Daniel Davis, Sherri Fulmer, Jamie Green, Chelsie Hauer, Evan Norfolk, Michelle Richner, Cory Siegrist, Wendy Smeal, Rebecca Stametz, Mary Solomon, Christina Yule, Patti Ephraim, Raquel Greer, Felicia Hill-Briggs, Teri Browne, Navdeep Tangri, Brian Bankes, Shakur Bolden, Patricia Danielson, Katina Lang-Lindsey, Suzanne Ruff, Lana Schmidt, Amy Swoboda, Peter Woods, Diana Clynes, Stephanie Stewart, Dori Schatell, Kristi Klicko, Brandi Vinson, Jennifer St Clair Russell, Kelli Collins, Jennifer Martin, Dale Singer, Diane Littlewood

Affiliations

¹ Division of General Internal Medicine, Duke University School of Medicine, Durham, NC.
² Department of Nephrology, Geisinger Commonwealth School of Medicine, Danville, PA.
³ Kidney Health Research Institute, Geisinger, Danville, PA.
⁴ Welch Center for Prevention, Epidemiology and Clinical Research, Baltimore, MD.
⁵ Division of General Internal Medicine, Johns Hopkins University, Baltimore, MD.
⁶ Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
⁷ Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC.
⁸ Center for Clinical Innovation, Institute for Advanced Application, Geisinger, Danville, PA.
⁹ Department of Nephrology, Geisinger Medical Center, Danville, PA.
¹⁰ Division of Nephrology, Duke University School of Medicine, Durham, NC.
¹¹ College of Social Work, University of South Carolina, Columbia, SC.
¹² Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, NC.
¹³ Department of Population Health Sciences, Duke University School of Medicine, Durham, NC.

Abstract

Rationale & objective: Chronic kidney disease (CKD) care is often fragmented across multiple health care providers. It is unclear whether patients rely mostly on their nephrologists or non-nephrologist providers for medical care, including CKD treatment and advice.

Study design: Cross-sectional study.

Setting & participants: Adults receiving nephrology care at CKD clinics in Pennsylvania.

Predictors: Frequency, duration, and patient-centeredness (range, 1 [least] to 4 [most]) of participants' nephrology care.

Outcome: Participants' reliance on nephrologists, primary care providers, or other specialists for medical care, including CKD treatment and advice.

Analytical approach: Multivariable logistic regression to quantify associations between participants' reliance on their nephrologists (vs other providers) and their demographics, comorbid conditions, kidney function, and nephrology care.

Results: Among 1,412 patients in clinics targeted for the study, 676 (48%) participated. Among these, 453 (67%) were eligible for this analysis. Mean age was 71 (SD, 12) years, 59% were women, 97% were white, and 65% were retired. Participants were in nephrology care for a median of 3.8 (IQR, 2.0-6.6) years and completed a median of 4 (IQR, 3-5) nephrology appointments in the past 2 years. Half (56%) the participants relied primarily on their nephrologists, while 23% relied on primary care providers, 18% relied on all providers equally, and 3% relied on other specialists. Participants' adjusted odds of relying on their nephrologists were higher for those in nephrology care for longer (OR, 1.08 [95% CI, 1.02-1.15]; P = 0.02), those who completed more nephrology visits in the previous 2 years (OR, 1.16 [95% CI, 1.05-1.29]; P = 0.005), and those who perceived their last interaction with their nephrologists as more patient-centered (OR, 2.63 [95% CI, 1.70-4.09]; P < 0.001).

Limitations: Single health system study.

Conclusions: Many nephrology patients relied on non-nephrologist providers for medical care. Longitudinal patient-centered nephrology care may encourage more patients to follow nephrologists' recommendations.

Keywords: Chronic kidney disease; fragmented care; nephrology care; patient-centeredness; patient-provider communication.