Improving nephrology service delivery - Accessing the specialist.

BACKGROUND: The increased prevalence of chronic kidney disease (CKD) is straining the medical workforce and healthcare budget. To improve efficiency, patients require streamlined access to renal and general practice specialist advice. OBJECTIVE: The aim of this article is to profile general practitioner (GP) referrals for patients with CKD and compare these referrals to national guidelines. METHODS: We conducted a retrospective analysis of 200 randomly selected outpatient referrals to the renal service at St George Hospital, Sydney, between 2008 and 2011. These referrals were compared against national referral guidelines. RESULTS: Declining renal function accounted for the majority (44%; n = 78) of referrals, while advice regarding hypertension management contributed to a further 21% (n = 38) of referrals. Fifteen per cent (n = 27) of patients were referred back to their GP after one visit, while 40% (n = 72) required follow-up beyond 12 months. When compared with the National nephrology referral guidelines, 25% (n = 42) of referrals did not meet the criteria. DISCUSSION: Access to renal specialists may be difficult because of bottlenecks in the public clinic, frustrating all parties concerned. If an alternative, more integrated, possibly web-based CKD support service existed, some formal reviews could be bypassed. This study provides preliminary data supporting the development of such a service, and simultaneously providing streamlined sup-port to the GP and relieving pressure on hospital clinics.

Predictive Modelling Risk Calculators and the Non Dialysis Pathway.

This guideline will review the current prediction models and survival/mortality scores available for decision making in patients with advanced kidney disease who are being considered for a non-dialysis treatment pathway. Risk prediction is gaining increasing attention with emerging literature suggesting improved patient outcomes through individualised risk prediction (1). Predictive models help inform the nephrologist and the renal palliative care specialists in their discussions with patients and families about suitability or otherwise of dialysis. Clinical decision making in the care of end stage kidney disease (ESKD) patients on a non-dialysis treatment pathway is currently governed by several observational trials (3). Despite the paucity of evidence based medicine in this field, it is becoming evident that the survival advantages associated with renal replacement therapy in these often elderly patients with multiple co-morbidities and limited functional status may be negated by loss of quality of life (7) (6), further functional decline (5, 8), increased complications and hospitalisations.