Abstract Background Benefits of early nephrology care are well-established, but as many as 40% of U.S. patients with end-stage renal disease (ESRD) do not see a nephrologist before its onset. Our objective was to evaluate the effect of proactive, population-based nephrologist oversight (PPNO) on chronic kidney disease (CKD) progression. Methods Retrospective control analysis of Kaiser Permanente Hawaii members with CKD using propensity score matching methods. We matched 2,938 control and case pairs of individuals with stage 3a CKD for the pre-PPNO period (2001–2004) and post-PPNO period (2005–2008) that were similar in other characteristics: age, gender, and the presence of diabetes and hypertension. After three years, we classified the stage outcomes for all individuals. We assessed the PPNO effect across all stages of progression with a χ2- test. We used the z-score test to assess the proportional differences in progression within a stage. Results The progression within the post-PPNO period was less severe and significantly different from the pre-PPNO period (p = 0.027). Within the stages, there were 2.6% more individuals remaining in 3a in the post-period (95% confidence interval [CI], 1.5% to 3.8%; P value < 0.00001). Progression from 3a to 3b was 2.2% less in the post-period (95% [CI], 0.7% to 3.6%; P value = 0.0017), 3a to 4/5 was 0.2% less (95% CI, 0.0% to 0.87%; P value = 0.26), and 3a to ESRD was 0.24% less (95% CI, 0.0% to 0.66%, P value = 0.10). Conclusions Proactive, population-based nephrologist oversight was associated with a statistically significant decrease in progression. With enabling health information technology, risk stratification and targeted intervention by collaborative primary and specialty care achieves population-level care improvements. This model may be applicable to other chronic conditions.

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.