title: The role of specialists in managing the health of populations with chronic illness: the example of chronic kidney disease.
abstract: OBJECTIVE
  Specialty care has been used to manage individual patients at the discretion of generalists but not to drive improvements at the population level.
  
  
  METHODS
  Observational longitudinal study.
  
  
  METHODS
  Kaiser Permanente Hawaii, with more than 10,000 members with documented chronic kidney disease.
  
  
  METHODS
  Rate of late referrals to nephrology care, defined as occurring within four months of end stage renal disease and the proportions of patients starting haemodialysis with a mature arteriovenous fistula and starting dialysis in the outpatient setting.
  
  
  METHODS
  Risk stratification of the entire population and unsolicited consultations provided by nephrologists to generalists, based on patients' risk level, enabled by an electronic population management database.
  
  
  RESULTS
  Between 2004 and 2008, the proportion of referrals occurring within four months of onset of end stage renal disease dropped from 37 of 116 (32%) to 10 of 84 (12%), P=0.001. The proportion of patients starting haemodialysis with a mature arteriovenous fistula increased from 19 of 108 (18%) to 27 of 76 (36%), P=0.006. The proportion of patients who started haemodialysis as outpatients increased from 39 of 113 (35%) to 47 of 84 (56%), P=0.003.
  
  
  CONCLUSIONS
  Turning the traditional referral system on its head by providing unsolicited, risk driven nephrology consultations is an effective strategy for increasing the quality of medical management of patients with chronic kidney disease in the primary care setting and improving the cost effective use of nephrology services. This approach may be broadly applicable to other specialty areas.
authors: Kaiser Permanente, Hawaii Region, Moanalua Medical Center, 3288 Moanalua Rd, Honolulu, HI 96819, USA. brian.j.lee@kp.org
authors: Brian J
authors: BJ
authors: Lee
authors: Ken
authors: K
authors: Forbes
mesh_terms: D000553:Ambulatory Care / Q000706:statistics & numerical data; D001166:Arteriovenous Shunt, Surgical; D016208:Databases, Factual; D005919:Glomerular Filtration Rate; D006254:Hawaii; D006801:Humans; D007676:Kidney Failure, Chronic / Q000175:diagnosis / Q000628:therapy*; D010819:Physician's Role; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D006435:Renal Dialysis / Q000706:statistics & numerical data*; D018570:Risk Assessment; D012307:Risk Factors