Initiatives to enhance referral patterns from primary care to specialist kidney care:a systematic review and...

To highlight data on interventions aimed at enhancing referral patterns from primary care to nephrology.

Systematic review and meta-analysis.

MEDLINE, Embase, Cochrane Library, CINAHL, Web of Science and PsycINFO.

Studies reporting interventions aimed at decreasing referral volume, reducing wait times and/or increasing guideline-concordant referrals in adult patients with chronic kidney disease from primary care to specialist kidney care, from inception to 15 April 2024.

Studies were subcategorised based on taxonomy of initiatives, type of intervention and single versus multi-faceted interventions. Our primary outcomes were changes to referral volume, wait times and proportion of guideline-concordant referrals. Data were pooled using a random effects model and a meta-analysis was conducted using pooled mean difference (MD) and OR.

20 studies used single and 13 used more than one intervention. Overall, interventions resulted in an increase in total referrals (MD: 19 referrals per month, 95% CI 7 to 30; I²=98%; p<0.001) and a non-significant decrease in the proportion of guideline-concordant referrals (OR: 0.32, 95% CI 0.09 to 1.16; I²=100%; p=0.08). These effects were consistent when stratified by single versus multi-faceted interventions, and by taxonomy of interventions. Interventions categorised as financial, regulatory or legislative incentives (n=2) led to an increase in guideline-concordant referrals (OR: 1.15, 95% CI 1.02 to 1.29; I²: 0%; p=0.02). Organisational changes showed a non-significant reduction in wait time of 24 days (95% CI -64 to 15, I²=99%; p=0.23) but tended to decrease guideline concordant referrals (OR: 0.17, 95% CI 0.03 to 0.86; I²: 100%; p=0.03).

Organisational changes decreased wait times. Overall, interventions increased referral volume and decreased guideline-concordant referrals. The data have implications for designing programmes to improve primary care-nephrology interface in kidney disease management.