Tuesday, 11 September 2007

Q and A: Impact of eGFR on Specialist Kidney Referrals

Q: We are looking for data to back up concerns that we have regarding the effect that eGFR has had or will have on clinics in terms of inappropriate referrals and compounded by the 18 week target.

Is there any audit data available which could be shared and which we could take to our Development/Service Improvement Lead for the Trust. We would like to be able to show how the 18 week target and more specifically, the 3 week new appointment target which comes in next March will cause us some concern.
Julie Batterton, Associate Directorate Manager, Nephrology & Renal Transplant Directorates Royal Liverpool & Broadgreen University Hospital Trust, Prescot Street, Liverpool

A: Dear Julie , my consultant colleague passed on your request for audit info re the impact of eGFR on specialist kidney referrals.

In general terms, the introduction of eGFR reporting and of CKD in QOF has lead to a substantial increase in new referrals to renal services - some appropriate (ie in line with the well publisied RCP RCGP guideline), but many inappropriate. Also we need to bear in mind that this last year has been the first year - so a lot of prevalent cases have been uncovered . You would know how many by looking at your local PCT and practice CKD observed as expected prevalence in the QMAS data - well worth doing - it essentially shows where there is educational need in primary care.

Systems that have been operating eGFR for some time and have good referal pathways in place have seen a fallback in referrals to manageable numbers - the key is excluding (by education - look at the Derby website) as well as encouraging proforma referrals that don't all need a traditional OPD - ie establishing (commissioning) virtual clinics - they do need real time!!

Richard Fluck in Derby (who has an excellent system) and Kevin Harris in Leicester/East Midlands Renal Network each have good local audit data - Kevin over a diverse range of providers.

The main issue arising nationally is the need to have robust, coordinated advance CKD care (predialysis , supportive and palliative) that ensures adequate preparation and choice for people with CKD Stages 4 and 5 - small numbers (in comparison to Stage 3 the overwhelming majority of whom should get the greatest amount of care in the primary/community setting) . You would know how good comparatively your pre-dialysis care is by looking at the proxies of pre-emtive transplant listing/transplanting and percentage who start haemodialysis via an AVF - data in the Renal Registry.

Let me know if I can be of more help.