Primary care clinician perspectives on automated nephrology e-consults for diabetic kidney disease: a pre-implementation qualitative study

Chi D Chu; Daniel Dohan; Michelle M Estrella; Michael G Shlipak; Delphine S Tuot

doi:10.1186/s12875-024-02454-w

Primary care clinician perspectives on automated nephrology e-consults for diabetic kidney disease: a pre-implementation qualitative study

BMC Prim Care. 2024 Jun 4;25(1):197. doi: 10.1186/s12875-024-02454-w.

Authors

Chi D Chu^{1

2

3}, Daniel Dohan⁴, Michelle M Estrella^{5

6}, Michael G Shlipak^{5

6}, Delphine S Tuot^{5

7}

Affiliations

¹ Department of Medicine, University of California, San Francisco, San Francisco, CA, 94110, USA. [email protected].
² Department of Medicine, Division of Nephrology, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, 1001 Potrero Ave, Bldg 100, Rm 342, San Francisco, CA, 94110, USA. [email protected].
³ Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco VA Health Care System, San Francisco, CA, USA. [email protected].
⁴ Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA.
⁵ Department of Medicine, University of California, San Francisco, San Francisco, CA, 94110, USA.
⁶ Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco VA Health Care System, San Francisco, CA, USA.
⁷ Department of Medicine, Division of Nephrology, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, 1001 Potrero Ave, Bldg 100, Rm 342, San Francisco, CA, 94110, USA.

Abstract

Background: Many patients with diabetic kidney disease (DKD) do not receive evidence-based, guideline-recommended treatment shown to reduce DKD progression and complications. Proactive electronic consultations (e-consults) are an emerging intervention strategy that could potentially allow nephrologists to provide timely and evidence-based guidance to primary care providers (PCPs) engaged in early DKD care.

Methods: The objective of this study was to explore perspectives about potential barriers and facilitators associated with a proactive e-consult program to improve DKD care delivery. We conducted semi-structured qualitative interviews with PCPs across three different health systems. Interview transcripts were reviewed in a rapid qualitative analysis approach to iteratively identify, refine, and achieve consensus on a final list of themes and subthemes.

Results: A total of 18 interviews were conducted. PCPs across all sites identified similar challenges to delivering guideline-recommended DKD care. PCPs were supportive of the proactive e-consult concept. Three major themes emerged surrounding (1) perceived potential benefits of proactive e-consults, including educational value and improved specialist access; (2) concerns about the proactive nature of e-consults, including the potential to increase PCP workload and the possibility that e-consults could be seen as documenting substandard care; and (3) leveraging of care teams to facilitate recommended DKD care, such as engaging clinic-based pharmacists to implement specialist recommendations from e-consults.

Conclusion: In this pre-implementation qualitative study, PCPs noted potential benefits and identified concerns and implementation barriers for proactive e-consults for DKD care. Strategies that emerged for promoting successful implementation included involving clinic support staff to enact e-consult recommendations and framing e-consults as a system improvement effort to avoid judgmental associations.

Keywords: Chronic kidney disease; Diabetic kidney disease; E-consults; Electronic consultation; Nephrology referral.

MeSH terms

Attitude of Health Personnel*
Diabetic Nephropathies* / therapy
Female
Humans
Interviews as Topic
Male
Nephrology
Physicians, Primary Care*
Primary Health Care
Qualitative Research*
Remote Consultation

Abstract

MeSH terms

Grants and funding