Table 2

Results and critical appraisal of included studies

StudyBaseline characteristicsResultsKey findingsStrengthsLimitationsAdditional points from critical appraisal
Age (years)Sex (male (%))eGFR (mL/min/1.73 m2)Urine ACR
Hingwala et al (2017)*Pretriage: not presented.

Post-triage: 68 (median).
Pretriage: not presented.

Post-triage: 50.3.
Pretriage: not presented.

Post-triage: 39 (median).
Pretriage: not presented.

Post-triage: 9.2 (median).
  • Referrals booked for appointment: not presented.

  • Median monthly referrals: 68/month (range 44–76).

  • Median wait time: 230 days (range: 126–355).

  • Referrals booked for appointment: 66%.

  • Median monthly referrals: 94 /month (range 61–147).

  • Median wait time 58 days (range: 48–69).

Monthly referral increase of 45%.
Median wait times improved (p<0.001).
Low-cost triage system.

Triage process allows for clinical judgement, such that ‘low-risk’ patients according to KFRE are identified for nephrology review where necessary.
Lack of data presented for pretriage period (eg, baseline characteristics and number of booking) to allow for detailed historical comparison (pre-riage).

No clinical or economic impact assessment of implementing KFRE triage system.

No long-term follow-up on patients triaged as low risk.

May not be applicable to teams operating under capacity without wait lists.
Washout period for 1 year when implementing criteria.

Additional capacity to see referrals (additional nephrologist hired in September 2013, physician-assistant led clinic from Sept 2012).

‘Hawthorne effect’.

Three centres.

No financial support. Authors declared no competing interests.
Hong et al (2020)*Not presentedNot presentedNot presentedNot presentedCompared with 2018 when KFRE-based triage implemented:
  • 25% fewer consults in 2019 (30% less than in 2017).

  • Fewer patients had a low‐risk KFRE at triage (46% vs 48%).

  • Fewer low‐risk patients had clinic follow‐up (50% vs 52%).

More low-risk patients remaining in clinic (86% vs 60%) had alternative reasons for follow-up (ie, eGFR < 30 mL/min, moderate proteinuria, or uncontrolled hypertension).
Implementing the KFRE-based triage system reduced overall and low-risk patient numbers in outpatient clinics.Triage system allowed for consultant discretion for low-risk patients to be followed upNo baseline characteristics presented for patients either preimplementation or postimplementation of the KFRE-based triage process.

Low-risk patients with eGFR <30 or moderate proteinuria still followed up.

Inability to calculate KFRE score for referrals at triage (28% in 2018, 36% in 2019) due to missing urine ACR.
Limited data therefore unable to compare if pretriage versus post-triage groups were similar.

Single centre.

Unclear if results are ‘significant’.

No comment on what was done for patients with missing ACR.
Smekal et al (2019)†‡Pre-KFRE implementation:
Patients: survey 10%<50; 28% 50–64; 22% 65–74; 39% ≥75.
Healthcare providers: not presented.

Post-KFRE implementation:
  • interviews 10% 50–64; 30% 65–74; 60%≥75.

  • survey 17%<50; 19% 50–64; 27% 65–74; 38%≥75.

Healthcare providers: not presented.
Pre-KFRE implementation:
  • Patients (survey): 60.

  • Healthcare providers (survey): 28.

Post-KFRE implementation:
  • Interviews: 50.

  • Survey: 57.

Healthcare providers
  • Interviews: 29

  • Survey: 27.

Not presentedNot presentedInterviews:
  • 9/23 (39%) patients and 17/75 (23%) providers interviewed.

  • Five themes were identified among patients and providers and two additional categories identified among providers only.

  • Majority of patients satisfied with their care in both periods with no overall differences. However, there were improvements in patients’ experience of access to care, caring staff and safety of care.

  • Of the 75 providers, 40 (53%) and 33 (44%) completed the preimplementation and postimplementation job satisfaction survey, respectively; no differences in providers’ job satisfaction.

Patients and healthcare providers reported
  • Improved the focus of MDT clinics by targeting high-risk patients.

  • Using KFRE to target care to high-risk patients was a key strength.

Enhanced the sustainability of the clinics.

Providers expressed concern that there may be inadequate access to and lower quality of care for low-risk patients discharged from multidisciplinary care, although patients did not experience this.

No difference in patients’ care experience.

No difference in healthcare provider job satisfaction.
Includes both patient and provider perspectives.

Presents both qualitative and quantitative data.
More healthcare providers than patients in qualitative component; data saturation was achieved in both groups.

Most patients interviewed had >5 years in MDT care prior to discharge so may not be representative of general nephrology patients.

Patients discharged from MDT clinics within previous 12 months so limited time period following implementation of risk approach.

Unable to pair presurvey and post-survey responses or establish response rate.

Single centre.
Limited to English-speaking participants.

Low response rate.

Detailed information on data collection and analysis, questions provided.

Mostly female providers.

Funder had no role in the project. Authors declared no competing interests.
Che et al (2020)§Not presentedNot presented<30Not presented470 (73%) continued follow-up in MCKC.

Of 142 (22%) discharged to primary care:
  • 52 (37%) died.

  • 15 (11%) rereferred to nephrology (at median 982 (IQR 560) days).

  • 8 (6%) initiated RRT (at median 850 (1411)) days; 5 (63%) for unforeseen acute illness).

31 (5%) discharged to general nephrology.
Discharge of a significant number of patients when moving to new criteria, few of whom ultimately required RRT that could have been prevented.’Low loss to follow-up’.Completeness of data and follow-up unclear.

May not be generalisable as based on one regional renal programme.
Unclear reason for chosen threshold or if this is the ideal level.

Limited data.

No comparison or control group.

No detail on missing data.
Sendak et al (2016)§Not presentedNot presentedNot presentedNot presentedOf 335 patients of 413 eligible:
73 (21.8 %) management changes:
  • 53 (72.6%) to nephrology.

  • 8 (11.0%) to primary care.

  • 7 (9.6%) lab recommendations.

  • 4 (5.5%) medication recommendations.

Average time-per-case per health round 2 min 12 s.

Of the remaining 262 (78.2%) patient screening did, however, identify:
  • 110 (42.0%) seeing a nephrologist.

  • 35 (13.3%) recently deceased.

  • 25 (9.5%) on dialysis.

Patients with CKD at high risk of progression to ESKD can be identified using validated algorithms applied to structured data that is readily available.

A significant proportion of patients identified in this way require management changes, including patients that require nephrology review.

Limited ability to screen out patients using structured data.

Health rounds can be performed relatively rapidly.
KFRE easily applicable.

Highlights additional patients for review in primary/specialty care.
No data on long-term outcomes.

Data from one renal programme, therefore, may not be generalisable.
Elderly patients.

Later months more efficient as workflow optimised – not taken into consideration for time per case.

Private healthcare setting so not generalisable.
  • Appraisal tool used for the studies:

  • *Joanna Briggs Institute Quasiexperimental study checklist.

  • †CASP Cohort Study Checklist.

  • ‡CASP Qualitative Studies Checklist (interviews).

  • §Centre for evidence-based management critical appraisal of a survey.

  • ACR, albumin:creatinine ratio; CASP, Critical Appraisal Skills Programme; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; ESKD, end-stage kidney disease; KFRE, Kidney Failure Risk Equation; MCKC, Multi-Care-Kidney-Clinic; MDT, multidisciplinary team; RRT, renal replacement therapy.