Croatia
Croatia (Hrvatska)
In soccer and medicine, Croatians are well known for their discipline, engagement and grit. The worldwide fame of a player like Luka Modrić is a clear example. He's scored many amazing goals with Real Madrid, and along with the national team Croatia will be a strong contender in the FIFA World Cup.
For the Croatians, prestige doesn't end on the pitch. As the oldest medical school, The University of Zagreb is the source of many scientific advances. It's only natural to feature science that comes from researchers of this prestigious institution.
Figure 1. Workup prior to Nephrology referral (zoom in for details)
The Kockasti enter the NephroWorldCup with a rather blunt indictment of the pre-nephrologist evaluation. Incomplete diagnostic workups of patients referred to Nephrology can be an additional, and reversible, drain on resources for a healthcare system that is already heavily constrained.
We've all been here before. The time and effort required to complete a basic workup of a kidney patient adds costs, delays, and frustration to both the patient and his/her healthcare providers. It's an investment that consumes more than returns and one whose scope the Croatian squad set out to clarify.
In this study, the researchers analyzed 184 patients (89 male and 95 female) who where referred to the nephrologist because of diagnosis of CKD 3A to 5. In the study patients underwent analysis of their 24-h ambulatory blood pressure as well as biochemical and hematological analyses. Of the 86% of patients suffering with hypertension, only 23% had an ambulatory blood pressure reading. Indeed most patients with CKD stages 3A, 3B, and 4 did not have an ambulatory BP measurement (Table 1). A small proportion of patients in different CKD stages had reported albumin in urine. The authors estimated that only 14% of the patients referred to the clinic had an appropriate complete work up prior to the referral (Figure 1).
Table 1. Appropriate diagnostic workup for patients stratified by CKD stage.
The researchers stress that a proper nephrology evaluation requires coordination with the patient's primary care provider. They note that an alarmingly low percentage of patients with "modifiable CKD" (CKD stages 3A, 3B) received ambulatory blood pressure measurement(s) (Figure 2).
Figure 2. The challenges of ambulatory blood pressure monitoring | Presented at the 2022 European Renal Association annual meeting | Courtesy of Dr. Dominque Guerrot (zoom in for details)
Note that the scientists don't blame primary care providers or nephrologists for the underutilization of pre-referral diagnostic testing. Understanding the scope of this problem is important to identify better practices and can be undertaken without finger pointing.
Communication between primary care providers and nephrologists is critical in improving the pre-referral diagnostic evaluation. Thus, we must contextualize how easy/difficult communication is between physicians in various healthcare environment. In nations with mature healthcare systems there are multiple ways in which generalists can communicate with specialists. For starters, some sophisticated electronic medical record platforms allow for easy communication. In other cases, physical proximity with each other helps close the communication gap. Alas the Croatian researchers did not assess possible interventions to improve cross-functional communication.
Table 2. Indications for nephrology referral | Courtesy of The American Family Physician and Dr. Edgar Lerma
As the Croatian team invites us to think about how we perform a general assessment of kidney disease in our patients, it is essential to remember that although simple, a complete and thorough evaluation is critical for the diagnosis and treatment success (Table 2). Many of these patients may require a kidney biopsy to establish a diagnosis, and even in high-income countries, seeing a specialist may take significant time out of the patient's schedule, notwithstanding travel costs and potential issues related to follow-up. With this paper, we are invited to communicate with our colleagues in primary care and educate them when questions about proper evaluation arise.