Risk-based referral model to nephrologist specialist care in Stockholm

Area of Science:

• Nephrology
• Public Health
• Health Economics

Background:

• Early-stage chronic kidney disease (CKD) management primarily occurs in primary care.
• KDIGO 2024 guidelines suggest using a 5-year kidney failure risk equation (KFRE) of 3-5% for nephrologist referrals.
• Assessing the impact of risk-based referral models versus traditional criteria is crucial for optimizing patient care pathways.

Purpose of the Study:

• To evaluate the effectiveness of a risk-based referral model for CKD patients compared to traditional referral criteria.
• To assess the performance of the Non-North American 4-variable KFRE and its recalibrated version in a North European setting.
• To determine the potential reduction in unnecessary referrals and optimize resource utilization.

Main Methods:

• Retrospective observational study of adults with eGFR < 60 mL/min/1.73m² from the SCREAM project cohort.
• Evaluation of the Non-North American 4-variable KFRE and recalibration for the local setting.
• Comparison of KFRE thresholds with Swedish and KDIGO 2012 criteria using sensitivity, specificity, and reclassification analyses.

Main Results:

• The study included 192,964 individuals, with 1.4% progressing to kidney replacement therapy (KRT).
• Recalibrated KFRE demonstrated superior prediction performance, sensitivity, and specificity compared to traditional criteria.
• Risk-based referral models, using higher thresholds, reduced unnecessary referrals by 23-25% while maintaining low missed case rates.

Conclusions:

• Transitioning to a risk-based referral model in a large North-European healthcare system can significantly decrease unnecessary referrals.
• This optimized referral strategy maintains a low rate of missed CKD cases.
• Implementing KFRE-based referrals enhances resource utilization in managing early-stage CKD.