Intended for healthcare professionals

Practice Quality Improvement Report

The role of specialists in managing the health of populations with chronic illness: the example of chronic kidney disease

BMJ 2009; 339 doi: (Published 08 July 2009) Cite this as: BMJ 2009;339:b2395
  1. Brian J Lee, nephrologist1,
  2. Ken Forbes, care management analyst2
  1. 1Kaiser Permanente, Hawaii Region, Moanalua Medical Center, 3288 Moanalua Rd, Honolulu, HI 96819, USA
  2. 2Kaiser Permanente, Hawaii Region, Care Management Institute, 2828 Paa Street, Honolulu, HI 96819
  1. Correspondence to: B J Lee brian.j.lee{at}
  • Accepted 29 April 2009


  • Problem Specialty care has been used to manage individual patients at the discretion of generalists but not to drive improvements at the population level.

  • Design Observational longitudinal study.

  • Setting Kaiser Permanente Hawaii, with more than 10 000 members with documented chronic kidney disease.

  • Key measures for improvement Rate of late referrals to nephrology care, defined as occurring within four months of end stage renal disease and the proportions of patients starting haemodialysis with a mature arteriovenous fistula and starting dialysis in the outpatient setting.

  • Strategies for change Risk stratification of the entire population and unsolicited consultations provided by nephrologists to generalists, based on patients’ risk level, enabled by an electronic population management database.

  • Effects of change Between 2004 and 2008, the proportion of referrals occurring within four months of onset of end stage renal disease dropped from 37 of 116 (32%) to 10 of 84 (12%), P=0.001. The proportion of patients starting haemodialysis with a mature arteriovenous fistula increased from 19 of 108 (18%) to 27 of 76 (36%), P=0.006. The proportion of patients who started haemodialysis as outpatients increased from 39 of 113 (35%) to 47 of 84 (56%), P=0.003.

  • Lessons learnt Turning the traditional referral system on its head by providing unsolicited, risk driven nephrology consultations is an effective strategy for increasing the quality of medical management of patients with chronic kidney disease in the primary care setting and improving the cost effective use of nephrology services. This approach may be broadly applicable to other specialty areas.

End stage renal disease is a major source of morbidity and mortality worldwide. In the minority of the 11% of adults with chronic kidney disease who progress to end stage renal disease, management by a nephrologist can slow progression and improve blood pressure control and the use of angiotensin converting enzyme …

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