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. 2022 Sep 29:13:20406223221108397.
doi: 10.1177/20406223221108397. eCollection 2022.

The dynamics of the general practitioner-nephrologist collaboration for the management of patients with chronic kidney disease before and after dialysis initiation: a mixed-methods study

Maxime Raffray  1 , Cécile Vigneau  2 , Cécile Couchoud  3 , Laetitia Laude  4 , Arnaud Campéon  5 , François-Xavier Schweyer  6 , Sahar Bayat  4
Affiliations

The dynamics of the general practitioner-nephrologist collaboration for the management of patients with chronic kidney disease before and after dialysis initiation: a mixed-methods study

Maxime Raffray et al. Ther Adv Chronic Dis. .

Abstract

Background: Effective collaboration between general practitioners (GP) and nephrologists is crucial in CKD care. We aimed to analyse GPs' and nephrologists' presence and involvement in CKD care and assess how they intertwine to shape patients' trajectories.

Methods: We conducted a mixed-methods study that included all patients with CKD who started dialysis in France in 2015 (the REIN registry) and a sample of nephrologists and GPs. We quantified professionals' presence through patients' reimbursed healthcare from the French National Health Data System, 2 years before and 1 year after dialysis start. Involvement in CKD care was derived from the nephrologists' and GPs' interviews.

Results: Among 8856 patients included, nephrologists' presence progressively increased from 29% to 67% of patients with a contact during the 2 years before dialysis start. However, this was partly dependent on the GPs' referral practices. Interviews revealed that GPs initially controlled the therapeutic strategy on their own. Although unease grew with CKD's management complexity, reducing their involvement in favour of nephrologists, GPs' presence remained frequent throughout the pre-dialysis period. Upon dialysis start, nephrologists' presence and involvement became total, while GPs' greatly decreased (48% of patients with a contact at month 12 after dialysis start). Collaboration was smooth when GPs maintained contact with patients and could contribute to their care through aspects of their specialty they valued.

Conclusions: This mixed-methods study shows presences and forms of involvement of GPs and nephrologists in CKD care adjusting along the course of CKD and unveils the mechanisms at play in their collaboration.

Keywords: care trajectories; chronic kidney disease; collaboration; general practitioner; healthcare data; mixed methods.

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Conflict of interest statement

Competing interests: The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work. In addition, the results presented in this paper have not been published previously in whole or part, except in abstract format.

Figures

Figure 1.
Figure 1.
Percentage of patients who saw a GP and nephrologist (including during dialysis sessions) at least once in a quarter before and after dialysis start (N = 8856 patients who started dialysis in France in 2015). Other medical specialties included anaesthesiology (16.8% of the total), cardiology (9.3%), internal medicine (7.6%), general surgery (7.4%), vascular surgery (7.3%) and endocrinology (5.5%).
Figure 2.
Figure 2.
Number and percentages of laboratory tests (a, b), total drugs (c, d) and drugs acting on the renin-angiotensin system (e, f) prescribed to the 8856 patients with CKD who started dialysis in France in 2015 according to the prescriber’s medical specialty in the 24 and 12 months before and after dialysis start, respectively. Reading example: During the last month before dialysis start (m–1), 175,000 laboratory tests were prescribed (a) of which 45% were prescribed by a nephrologist (b). During the last month before dialysis (m–1), ~70 000 drugs were prescribed (c) of which 50% were prescribed by a GP (d).
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