Nephrology consults increase
Authors: Bryce A. Kiberd, Steven D. Soroka
Journal: Kidney International (2010)

To the Editor: The article by Jain et al on ‘When laboratories report estimated glomerular filtration rates in addition to serum creatinines, nephrology consults increase” deserves further comment on both the cause and the magnitude of increase in nephrology consultations.1.Jain A.K. McLeod I. Huo C. et al.When laboratories report estimated glomerular filtration rates in addition to serum creatinines, nephrology consults increase.Kidney Int. 2009; 76: 318-323Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar A more rigorous approach would have been to look at secular trends in nephrology consults in other regions that had not implemented routine estimated glomerular filtration rate (eGFR) reporting rather than using dermatology consults as the comparator. Figure 1 shows the new outpatient nephrology consults at Capital Health, Halifax, Nova Scotia, over a similar time period. We provide nephrology consultant service for a relatively stable catchment population of approximately 700,000–800,000 people. Routine reporting or at request eGFR had not been implemented in the province; however, we experienced a similar increase in consultations (27 vs. 24%) at a time similar to the introduction of eGFR in Ontario. The absolute increase, relative to the catchment population, is also comparable. The sudden increase at our center was a response to growing referrals and a desire to reduce wait times, implying that the stimulus was already in place. The increase in demand also predated a reduction in the upper limit of normal for serum creatinine for women by the laboratory, which also appears to have increased the referrals of older women. Although analyses of administrative databases are convenient they may not accurately assess the magnitude of the impact. Nephrology consults underestimate actual and potential referrals for several reasons. There may be an increase in referrals to general internists for patients in areas geographically remote, wait lists grow, and sometimes we contact referring physicians by phone or letter instructing investigation and treatment of less urgent cases, thereby avoiding the need for a billed consult. Although unsubstantiated, as wait lists grow some primary care physicians simply forgo less urgent referrals. Finally, some of the increase is not low eGFR. There are a small but growing number of nondiabetic patients referred with isolated microalbuminuria. Reporting that labels someone as having an abnormal lab test (eGFR or creatinine) results in referral without increasing the knowledge of the primary care provider. We have recently seen a decrease in nephrology consults and feel that this may in part be the result of education targeted at the primary practitioner on the evaluation and treatment of chronic kidney disease. Now that Jain et al.1.Jain A.K. McLeod I. Huo C. et al.When laboratories report estimated glomerular filtration rates in addition to serum creatinines, nephrology consults increase.Kidney Int. 2009; 76: 318-323Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar have demonstrated increase consult rates we must examine the impact on health outcomes and costs for those now being referred. Given staggering increases in health care expenditures we should strive for the evidence that this increased referral (age >70 with eGFR between 45–60 ml/min per 1.73 m2) has measurable benefit. As an example that the benefits derived may be limited in the older population, the US Preventive Services Task Force now recommends against routine colorectal screening in individuals >75 years of age because of reduced benefits from competing risks of death.2.Screening for Colorectal Cancer, March 2009. U.S. Preventive Services Task Force. Agency for Healthcare Research and Quality: Rockville, MD. http://www.ahrq.gov/clinic/uspstf/uspscolo.htmGoogle Scholar Electronic medical records that incorporate decision layer support based on eGFR and increased risk responsive to intervention would be a useful next step.