Patients with chronic kidney disease (CKD) are increasing in most developed societies, yet in America may be recognized by providers only about 11% of the time (Stevens, et al. J Am Soc Nephrol 2005;16:2439). Effective renal preservation programs are available to delay the onset of end-stage renal disease, so CKD non-recognition is a major barrier for their execution. Available solutions to this barrier include provider educational programs, Medicare financial rewards for provider performance, and expedited claims processing for compliant providers. Each solution is fraught with difficulties such as expense, “recipient burnout,” fear of loss of patient base, inertia, and “cherry picking” of easy cases. An alternative option in health care systems linked by information technology (IT) might be termed a “gentle reminder” system (GRS). This would involve an automatic search of all patients who have had a blood test in a particular month and to track those with a creatinine level drawn to examine all their values over the preceding year. If any were above some arbitrary level (we picked 1.4 as a start), the patients were classified as to whether they had seen a nephrologist within that year. For those who had not, we would generate a GRS which would be an alert included in the patient's electronic record stating to the provider that a renal consultation might be considered. In this first phase of GRS development we examined the scope of the problem in our academic VA center, which has a patient enrolment of about 46,000. We looked for those patients categorized in 0.1 mg/dL increments of serum creatinine from 1.4 to 2.6 who were not enrolled in a renal clinic. The results revealed that most patients in the ranges of Stage 2 and 3 CKD are unrecognized (total patients with creatinines on the abscissa in dark bars and those not in renal clinics in light bars). Overall, we recognized only 43% of CKD patients over this range compared to 22 to 29% nationally (NHANES). The GRS is now active. Problems with this approach that need to be solved are it is intrusive on the practice patterns of primary care providers, it is strictly applicable only to a “command” type system typical of government, and it is not yet readily applicable to clinics that do not use IT. These difficulties may lessen with GRS usage.
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