The high prevalence of chronic kidney disease (CKD) in the adult population,1 the fact that it is underdiagnosed and its progressive but modifiable nature have made necessary to develop specific prevention and detection strategies. The aim of these strategies is to avoid associated cardiovascular complications, progression of CKD and inadequate prescription of medications. The aim is also to avoid late referral to the nephrologist to avoid a delay in adequate control of the complications of advanced CKD which makes difficult to prepare the patient in advance for renal replacement therapy.

Primary prevention of CKD in the at-risk population is essentially based on detecting kidney disease and preventing renal progression factors. CKD is detected through estimation of glomerular filtration rate from creatinine-derived formulas and determining the albumin/creatinine ratio in a first morning urine sample. Prevention includes controlling blood pressure, optimisation of blood glucose control in diabetics, avoiding smoking and obesity, and control of dyslipidaemia and other cardiovascular risk factors.2 The detection and confirmation of CKD requires follow-up by the primary care physician and a nephrology specialist when necessary. Over the last ten years, thanks to the close collaboration and coordination achieved between nephrology and primary care, consensus documents have been published by the main scientific societies involved in care of kidney patients.3,4 However, not so much is known about the real impact on kidney health care. The reason for this gap of knowledge is related to the fact that nephrology speciality has always been seen as a “necessarily hospital-based specialist area”.

We assessed the efficiency of an out-of-hospital nephrology programme (ONP) implemented progressively over ten years with respect to control of the demand for CKD care in the Barcelona Esquerra Integral Health Area. We compared nephrology referrals in the fourth year of implementation (2010) to referrals after a further four years (2014).

The Integral Health Areas (IHA) were set up as a project by the Barcelona Health Consortium and health service providers with the aim of improving healthcare in the city of Barcelona through the effective coordination of the providers and healthcare professionals. There are four IHAs: “Norte”, “Esquerra”, “Derecha” and “Litoral”. Our experience came under the scope of the Barcelona Esquerra Integral Health Area. This area has a population of 524,395, which is 35% of the population of Barcelona and 7% of the population of Catalonia, for which the Nephrology and Kidney Transplant Department at Hospital Clínic is the single point of referral for the speciality.

The mean age of the patients who were new nephrology referrals was 74 from 2004 to 2009 and 70 from 2010 to 2014. The median age showed a similar decrease between the two periods, 79 and 74 respectively.

The reason for the first referral to nephrology was renal failure, estimated GFR <60ml/min/1.73m2, in 72% of patients referred from primary care in IHA-BE territory. A 19% of patients were consulted for proteinuria >1g/d with a normal kidney function and the remaining 9% were patients seen in nephrology for a other kidney disorder.

The new referrals seen in nephrology during the period 2004–2014 requested from primary care in the IHA-BE territory are shown in Fig. 2. These referals are grouped according to the provider and the ONP mode: virtual only or virtual and face-to-face. The number of new referrals from the primary care centres to be seen as face-to-face in nephrology consults decreased from the date of implementation of the face-to-face mode, while the number of new referrals with virtual nephrology consults remained at the same level on the evolution curve.

Fig. 2.

Number of new nephrology referrals referred from IHA-BE in the period 2004–2014. The arrows indicate the year of implementation of face-to-face Nephrology consulting.

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Table 2 shows the impact of the ONP on the relationship between care levels. The effective referral ratio calculated as the number of new nephrology referrals and the estimated CKD in the population tin primary care decreased significantly at the centres with ONP including face-to-face consulting.

This study is the first of its kind in Spain to analyse the impact of out-of-hospital nephrology care depending on whether the nephrologist consult is virtual or face-to-face, and the influence on referrals to specialised hospital nephrology care.

In 2006, we started an ONP in one of the three CAPSBE centres run by the ICS and Hospital Clínic de Barcelona. We later expanded the programme to the remaining two CAPSBE primary health centres and by 2010 we had expanded to eight more basic health areas managed by the ICS. The ONP provided a referral nephrologist, consultancy for case reports and continuing education sessions. The consultation was organised through the referral nephrologist by email and in person with the nephrologist travelling to the primary health centre. In the rest of the IHA-BE basic health areas only virtual consultancy has been available by email. The adequacy of the primary care referral to nephrology was assessed by a nephrologist, not involved in the out-of-hospital consultancy, for the entire IHA-BE territory, regardless of whether the referral nephrologist for the PHC was virtual only or also face-to-face.

In 2015, in line with the strategy to complement the high complexity of our tertiary hospital on the development of health policies on care provision for the chronically ill, it was decided to extend the ONP to the entire territory of the IHA-BE, beyond the limitation of the “Reform of Specialised Care”, with respect to nephrology being considered as a purely “hospital-based specialist area”. In the established framework of an organisational model based on, among other axioms, decision making from clinical knowledge and the use of information system tools to facilitate coordination between the different levels of care,6 we analysed the impact of the ONP in terms of controlling the demand for referral to the nephrology department throughout the period 2004–2014, in order to assess how the ONP was extended to all of the basic health areas of reference.7

The referral ratio of the number of new referrals to the estimated population with CKD remained unchanged even in a population that is older, and consequently more chronic, population, suggesting better efficacy by primary care in the period analysed. The decrease in the referral ratio was higher in the basic health areas with an ONP implemented with face-to-face consulting in addition to the virtual consultancy. The notable improvement, with a drop in the referral ratio of over 44% in basic health areas 2A, 2B, 2D and 3B, completely coincided with the implementation of face-to-face nephrology consulting in the period analysed. This shows that the degree of collaboration between primary and specialised care is enhanced by the closer contact between the two areas.

Our study does have certain limitations. Firstly, the sociodemographic characteristics of the assigned population may contribute to differences in demand in the different basic health areas. CKD can access care in the public health system at different stages of evolution and the rate of referral to specialised care is therefore heterogeneous. Moreover, the complexity of the service provision and process management within the IHA-BE territory may affect referral to nephrology. Secondly, the nephrology referral rate registers the appointments made, but we do not know how many requests for referral from primary care were rejected.

With the increased in life expectancy of the general population and in patients with advanced CKD, the amount of care aiming to guarantee quality of life also increases. Of course this is a relative depending on the disease causing CKD (e.g. diabetes mellitus), personal aspects (education), psychosocial aspects (family integration), adaptation to the environment (social integration), and therapeutic advances8 (e.g. erythropoiesis-stimulating agents). Continuity of care promotes a more effective and trusting relationship between patients and healthcare professionals, and helps to improve understanding of health problems and better adherence to the treatment prescribed. These benefits are mostly perceived in patients who need to visit the primary care physician frequently. It was recently reported that patients with continuity of care in primary care, more than 18 visits in the study period of two years (2011–2013), had a 12.49% reduction of hospital stays as compared with patients with less continuity of care.9

The approach in terms of health to population ageing, chronicity and associated mortality requires cooperation between the different levels of care and overcoming of the gap between primary and specialised care10 if we are to achieve efficiency, effectiveness and justice in the use of healthcare resources. Out-of-hospital nephrology provides the “continued care” of the chronic renal patient.

The ONP, particularly those that encourage involvement of the specialist in the healthcare team in person, in line with the “open hospital, without walls” concept,11 may overcome the gap between primary and hospital care in a radical but controlled manner, helping to respond to the challenges of chronicity, ageing and dependence. Studies based on the progressive indicators in CKD, percentage of hospitalisations, etc. will contribute more knowledge to the clinical impact of out-of-hospital nephrology.

The authors have no conflicts of interest to declare.