Initiatives to enhance referral patterns from primary care to specialist kidney care:a systematic review and meta-analysis.

Objectives: To highlight data on interventions aimed at enhancing referral patterns from primary care to nephrology. Design: Systematic review and meta-analysis. Data sources: MEDLINE, Embase, Cochrane Library, CINAHL, Web of Science and PsycINFO. Eligibility criteria: Studies reporting interventions aimed at decreasing referral volume, reducing wait times and/or increasing guideline-concordant referrals in adult patients with chronic kidney disease from primary care to specialist kidney care, from inception to 15 April 2024. Data extraction and synthesis: Studies were subcategorised based on taxonomy of initiatives, type of intervention and single versus multi-faceted interventions. Our primary outcomes were changes to referral volume, wait times and proportion of guideline-concordant referrals. Data were pooled using a random effects model and a meta-analysis was conducted using pooled mean difference (MD) and OR. Results: 20 studies used single and 13 used more than one intervention. Overall, interventions resulted in an increase in total referrals (MD: 19 referrals per month, 95% CI 7 to 30; I2=98%; p<0.001) and a non-significant decrease in the proportion of guideline-concordant referrals (OR: 0.32, 95% CI 0.09 to 1.16; I2=100%; p=0.08). These effects were consistent when stratified by single versus multi-faceted interventions, and by taxonomy of interventions. Interventions categorised as financial, regulatory or legislative incentives (n=2) led to an increase in guideline-concordant referrals (OR: 1.15, 95% CI 1.02 to 1.29; I2: 0%; p=0.02). Organisational changes showed a non-significant reduction in wait time of 24 days (95% CI -64 to 15, I2=99%; p=0.23) but tended to decrease guideline concordant referrals (OR: 0.17, 95% CI 0.03 to 0.86; I2: 100%; p=0.03). Conclusion: Organisational changes decreased wait times. Overall, interventions increased referral volume and decreased guideline-concordant referrals. The data have implications for designing programmes to improve primary care-nephrology interface in kidney disease management.