title: Evaluating the implementation strategy for estimated glomerular filtration rate reporting in Manitoba: the effect on referral numbers, wait times, and appropriateness of consults.
abstract: BACKGROUND
  Chronic kidney disease screening using estimated glomerular filtration rate (eGFR) reporting is standard in many regions. With its implementation, many centres have had higher referral rates and increased wait times to see nephrologists.
  
  
  OBJECTIVE
  Manitoba began eGFR reporting in October 2010. We measured the effect of eGFR reporting on referral rates, wait times, and appropriateness of referrals after an educational intervention.
  
  
  METHODS
  An interrupted time series design was used.
  
  
  METHODS
  This study took place in Manitoba, Canada.
  
  
  METHODS
  All referrals to the Manitoba Renal Program in the period prior to eGFR reporting between April 1, 2010 and September 30, 2010 were compared with a post period between January 1, 2011 and June 30, 2011.
  
  
  METHODS
  Data on demographics, co-morbidities, referral numbers and wait times were compared between periods. Appropriateness of consults was also measured after eGFR implementation.
  
  
  METHODS
  Prior to eGFR reporting, primary care physicians underwent educational interventions on eGFR interpretation and referral guidelines. Referral rates and wait times were compared between periods using generalized linear models. Chart audits of a random sample of 232 patients in the pre period and 239 patients in the post period were performed.
  
  
  RESULTS
  The pre and post eGFR reporting referral rate was 116 and 152 referrals/month, respectively. Average wait times in the pre and post eGFR reporting was 113 and 115 days, respectively. Non-urgent referral wait times increased by 40 days immediately post reporting, while urgent median referral wait times had a more gradual increase. Despite our intervention, inappropriate consultations post eGFR reporting was 495/790 (62.7%).
  
  
  CONCLUSIONS
  Our study did not measure the intervention's success on primary care providers, which may have affected our appropriateness data. Our time series design was not powered to find a statistically significant difference in referral numbers. Residual confounding of our results was possible given the retrospective nature of our study.
  
  
  CONCLUSIONS
  Despite our educational intervention, the inappropriate referrals remained high, and wait times increased. Other systemic interventions should be considered to attenuate the potential negative effects of eGFR reporting and ensure timely access for patients needing specialist consultation.
authors.affiliation: University of Toronto, Toronto, ON Canada ; Department of Medicine, Section of Nephrology, University of Manitoba, Winnipeg, MB Canada.
authors.forename: Jay
authors.initials: J
authors.lastname: Hingwala
authors.affiliation: Department of Medicine, Section of Nephrology, University of Manitoba, Winnipeg, MB Canada.
authors.forename: Sandip
authors.initials: S
authors.lastname: Bhangoo
authors.affiliation: St. Boniface General Hospital, Winnipeg, MB Canada.
authors.forename: Brett
authors.initials: B
authors.lastname: Hiebert
authors.affiliation: Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON Canada.
authors.forename: Manish M
authors.initials: MM
authors.lastname: Sood
authors.affiliation: Department of Medicine, Section of Nephrology, University of Manitoba, Winnipeg, MB Canada ; Seven Oaks General Hospital Renal Program, 2300 Mcphillips Street, 2PD12, Winnipeg, R2V 3M3 MB Canada.
authors.forename: Claudio
authors.initials: C
authors.lastname: Rigatto
authors.affiliation: Department of Medicine, Section of Nephrology, University of Manitoba, Winnipeg, MB Canada ; Seven Oaks General Hospital Renal Program, 2300 Mcphillips Street, 2PD12, Winnipeg, R2V 3M3 MB Canada.
authors.forename: Navdeep
authors.initials: N
authors.lastname: Tangri
authors.affiliation: Department of Medicine, Section of Nephrology, University of Manitoba, Winnipeg, MB Canada ; Seven Oaks General Hospital Renal Program, 2300 Mcphillips Street, 2PD12, Winnipeg, R2V 3M3 MB Canada.
authors.forename: Paul
authors.initials: P
authors.lastname: Komenda
keywords: Quality improvement; Referral; eGFR