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Kidney Week

Abstract: FR-PO253

Developing a System to Track and Reinstate Kidney Patients Lost to Follow-Up

Session Information

Category: CKD (Non-Dialysis)

  • 1902 CKD (Non-Dialysis): Clinical, Outcomes, and Trials

Author

  • Lo, Lowell J., UCSF, San Francisco, California, United States

Group or Team Name

  • UCSF Nephrology & Hypertension Faculty Practice Clinic Team
Background


In the care of chronic diseases, reducing the patients lost to follow-up (LTFU) is an important way to improve outcomes. At our tertiary academic center, we identified that approximately 24% of patients seen over six months had been instructed to follow-up in the clinic but did not within the recommended time frame. We designed a method to trigger an alert for these patients and contact them to schedule appointments.

Methods



Leveraging alerts from our electronic medical record (EMR), we generated an LTFU report that identifies patients who did not return to the clinic as requested by the providers. The alerts were dependent on physician participation in an EMR follow-up trigger. Clinical staff called these patients and classified them into three groups: scheduled (appointment made successfully), no need to return (patients transitioned to dialysis, transferred to another nephrologist, or died), or call back (unable to reach or refused appointment). We also recorded individual conditions that could contribute to LTFU.

Results



Physician participation in the EMR trigger system was 76.5%. Over nine months, using our EMR alert and calling system, we reduced the percentage of LTFU patients from 24% to 3.8%. Of the 418 LTFU patients, we successfully scheduled 225 (54%) patients, identified 34 (8.1%) no need to return patients, and continued to reach out monthly to 157 (38%) patients. Among patients LTFU, a majority did not provide a reliable method to be contacted.

Conclusion


Retention in care is associated with improved outcomes. Our study identified a method by which patients LTFU were identified. Majority of the patients were able to have appointments successfully scheduled. Vulnerable patients may benefit from early identification of risk of LTFU. A limitation of our study is that we lack outcome data on patients who were LTFU and the development and implementation of the system is time-intensive.