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Primary Care Management of Chronic Kidney Disease

Journal of General Internal Medicine volume 26, pages 386–392 (2011)Cite this article

Abstract

Background

Chronic kidney disease (CKD) causes substantial morbidity and mortality; however, there are limited data to comprehensively assess quality of care in this area.

Objective

To assess quality of care for CKD according to patient risk and identify correlates of improved care delivery.

Design

Retrospective cohort.

Setting

Fifteen health centers within a multi-site group practice in eastern Massachusetts.

Participants

166 primary care physicians caring for 11,774 patients with stages 3 or 4 CKD defined as two estimated glomerular filtration rates (eGFR) between 15 and 60.

Main Measures

Two measures of kidney disease monitoring, five measures of cardiovascular disease management, four measures of metabolic bone disease and anemia management, and one measure of drug safety were extracted from the electronic health record. Primary care recognition of CKD was assessed as a problem list diagnosis, and nephrology co-management was assessed as at least one visit with a nephrologist in the prior 12 months.

Key Results

Overall, 46% of patients were high risk for death based on the presence of diabetes, proteinuria, or an eGFR <45. Seventy percent of patients lacked annual urine protein testing, 46% had a blood pressure ≥130/80 mmHg and 25% were not receiving appropriate angiotensin blockade. Appropriate screening for anemia was common (76%), while screening rates for metabolic bone disease were low. Use of potentially harmful drugs was common (26%). Primary care physician recognition and nephrology co-management were both associated with improved quality of care, though rates of both were low (24% and 10%, respectively).

Conclusions

Significant deficiencies in the quality of CKD care exist. Opportunities for improvement include increasing physician recognition of CKD and improving collaborative care with nephrology.

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References

  1. Coresh J, Selvin E, Stevens LA, et al. Prevalence of chronic kidney disease in the United States. Jama. 2007;298(17):2038–47.

    PubMed  Article  CAS  Google Scholar 

  2. K/DOQI. Clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis. 2002;39(2 Suppl 1):S1–266.

    Google Scholar 

  3. K/DOQI. Clinical practice guidelines for management of dyslipidemias in patients with kidney disease. Am J Kidney Dis. 2003;41(4 Suppl 3):S1–91.

    Google Scholar 

  4. Matsushita K, van der Velde M, Astor BC, et al. Association of estimated glomerular filtration rate and albuminuria with all-cause and cardiovascular mortality in general population cohorts: a collaborative meta-analysis. Lancet. 2010;375(9731):2073–81.

    PubMed  Article  Google Scholar 

  5. Levey AS, Coresh J, Balk E, et al. National kidney foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern Med. 2003;139(2):137–47.

    PubMed  Google Scholar 

  6. Zandi-Nejad K, Brenner BM. Strategies to retard the progression of chronic kidney disease. Med Clin North Am. 2005;89(3):489–509.

    PubMed  Article  Google Scholar 

  7. Minutolo R, De Nicola L, Mazzaglia G, et al. Detection and awareness of moderate to advanced CKD by primary care practitioners: a cross-sectional study from Italy. Am J Kidney Dis. 2008;52(3):444–53.

    PubMed  Article  Google Scholar 

  8. Boulware LE, Troll MU, Jaar BG, Myers DI, Powe NR. Identification and referral of patients with progressive CKD: a national study. Am J Kidney Dis. 2006;48(2):192–204.

    PubMed  Article  Google Scholar 

  9. Stevens LA, Fares G, Fleming J, et al. Low rates of testing and diagnostic codes usage in a commercial clinical laboratory: evidence for lack of physician awareness of chronic kidney disease. J Am Soc Nephrol. 2005;16(8):2439–48.

    PubMed  Article  Google Scholar 

  10. Fox CH, Brooks A, Zayas LE, McClellan W, Murray B. Primary care physicians' knowledge and practice patterns in the treatment of chronic kidney disease: an Upstate New York Practice-based Research Network (UNYNET) study. J Am Board Fam Med. 2006;19(1):54–61.

    PubMed  Article  Google Scholar 

  11. Lea JP, McClellan WM, Melcher C, Gladstone E, Hostetter T. CKD risk factors reported by primary care physicians: do guidelines make a difference? Am J Kidney Dis. 2006;47(1):72–7.

    PubMed  Article  Google Scholar 

  12. Tseng CL, Kern EF, Miller DR, et al. Survival benefit of nephrologic care in patients with diabetes mellitus and chronic kidney disease. Arch Intern Med. 2008;168(1):55–62.

    PubMed  Article  Google Scholar 

  13. Philipneri MD, Rocca Rey LA, Schnitzler MA, et al. Delivery patterns of recommended chronic kidney disease care in clinical practice: administrative claims-based analysis and systematic literature review. Clin Exp Nephrol. 2008;12(1):41–52.

    PubMed  Article  Google Scholar 

  14. Stevens PE, O'Donoghue DJ, de Lusignan S, et al. Chronic kidney disease management in the United Kingdom: NEOERICA project results. Kidney Int. 2007;72(1):92–9.

    PubMed  Article  CAS  Google Scholar 

  15. Minutolo R, Sasso FC, Chiodini P, et al. Management of cardiovascular risk factors in advanced type 2 diabetic nephropathy: a comparative analysis in nephrology, diabetology and primary care settings. J Hypertens. 2006;24(8):1655–61.

    PubMed  Article  CAS  Google Scholar 

  16. Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of diet in renal disease study group. Ann Intern Med. 1999;130(6):461–70.

    PubMed  CAS  Google Scholar 

  17. National Committee For Quality Assurance Web Site. HEDIS and quality measurement. http://www.ncqa.org/tabid/59/Default.aspx. Accessed September, 14, 2010.

  18. KDOQI. Clinical practice guidelines and clinical practice recommendations for diabetes and chronic kidney disease. Am J Kidney Dis. 2007;49(2 Suppl 2):S12–154.

    Google Scholar 

  19. Dinneen SF, Gerstein HC. The association of microalbuminuria and mortality in non-insulin-dependent diabetes mellitus. A systematic overview of the literature. Arch Intern Med. 1997;157(13):1413–8.

    PubMed  Article  CAS  Google Scholar 

  20. Gerstein HC, Mann JF, Yi Q, et al. Albuminuria and risk of cardiovascular events, death, and heart failure in diabetic and nondiabetic individuals. Jama. 2001;286(4):421–6.

    PubMed  Article  CAS  Google Scholar 

  21. Fox CH, Swanson A, Kahn LS, Glaser K, Murray BM. Improving chronic kidney disease care in primary care practices: an upstate New York practice-based research Network (UNYNET) Study. J Am Board Fam Med. 2008;21(6):522–30.

    PubMed  Article  Google Scholar 

  22. Akbari A, Swedko PJ, Clark HD, et al. Detection of chronic kidney disease with laboratory reporting of estimated glomerular filtration rate and an educational program. Arch Intern Med. 2004;164(16):1788–92.

    PubMed  Article  Google Scholar 

  23. Rutkowski M, Mann W, Derose S, et al. Implementing KDOQI CKD definition and staging guidelines in Southern California Kaiser Permanente. Am J Kidney Dis. 2009;53(3 Suppl 3):S86–99.

    PubMed  Article  Google Scholar 

  24. Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med. 2004;351(13):1296–305.

    PubMed  Article  CAS  Google Scholar 

  25. Smith DH, Gullion CM, Nichols G, Keith DS, Brown JB. Cost of medical care for chronic kidney disease and comorbidity among enrollees in a large HMO population. J Am Soc Nephrol. 2004;15(5):1300–6.

    PubMed  Article  Google Scholar 

  26. Parikh NI, Hwang SJ, Larson MG, Meigs JB, Levy D, Fox CS. Cardiovascular disease risk factors in chronic kidney disease: overall burden and rates of treatment and control. Arch Intern Med. 2006;166(17):1884–91.

    PubMed  Article  Google Scholar 

  27. Snyder JJ, Collins AJ. KDOQI hypertension, dyslipidemia, and diabetes care guidelines and current care patterns in the United States CKD population: National Health and Nutrition Examination Survey 1999-2004. Am J Nephrol. 2009;30(1):44–54.

    PubMed  Article  Google Scholar 

  28. Minutolo R, De Nicola L, Zamboli P, et al. Management of hypertension in patients with CKD: differences between primary and tertiary care settings. Am J Kidney Dis. 2005;46(1):18–25.

    PubMed  Article  Google Scholar 

  29. Hoy T, Fisher M, Barber B, Borker R, Stolshek B, Goodman W. Adherence to K/DOQI practice guidelines for bone metabolism and disease. Am J Manag Care. 2007;13(11):620–5.

    PubMed  Google Scholar 

  30. Rocco MV. Disease management programs for CKD patients: the potential and pitfalls. Am J Kidney Dis. 2009;53(3 Suppl 3):S56–63.

    PubMed  Article  Google Scholar 

  31. Sequist TD, Fitzmaurice GM, Marshall R, et al. Cultural competency training and performance reports to improve diabetes care for black patients: a cluster randomized, controlled trial. Ann Intern Med. 2010;152(1):40–6.

    PubMed  Google Scholar 

  32. Wyatt C, Konduri V, Eng J, Rohatgi R. Reporting of estimated GFR in the primary care clinic. Am J Kidney Dis. 2007;49(5):634–41.

    PubMed  Article  Google Scholar 

  33. Hemmelgarn BR, Manns BJ, Lloyd A, et al. Relation between kidney function, proteinuria, and adverse outcomes. Jama. 303(5);423-429.

  34. Winkelmayer WC, Glynn RJ, Levin R, Owen WF Jr, Avorn J. Determinants of delayed nephrologist referral in patients with chronic kidney disease. Am J Kidney Dis. 2001;38(6):1178–84.

    PubMed  Article  CAS  Google Scholar 

  35. Mendelssohn DC, Kua BT, Singer PA. Referral for dialysis in Ontario. Arch Intern Med. 1995;155(22):2473–8.

    PubMed  Article  CAS  Google Scholar 

  36. O'Hare AM, Hailpern SM, Pavkov ME, et al. Prognostic implications of the urinary albumin to creatinine ratio in veterans of different ages with diabetes. Arch Intern Med. 170(11):930-936.

  37. Foy R, Hempel S, Rubenstein L, et al. Meta-analysis: effect of interactive communication between collaborating primary care physicians and specialists. Ann Intern Med. 2010;152(4):247–58.

    PubMed  Google Scholar 

  38. Chertow GM, Lee J, Kuperman GJ, et al. Guided medication dosing for inpatients with renal insufficiency. JAMA. 2001;286(22):2839–44.

    PubMed  Article  CAS  Google Scholar 

  39. Jain A, Atreja A, Harris CM, Lehmann M, Burns J, Young J. Responding to the rofecoxib withdrawal crisis: a new model for notifying patients at risk and their health care providers. Ann Intern Med. 2005;142(3):182–6.

    PubMed  Google Scholar 

  40. Rodondi N, Peng T, Karter AJ, et al. Therapy modifications in response to poorly controlled hypertension, dyslipidemia, and diabetes mellitus. Ann Intern Med. 2006;144(7):475–84.

    PubMed  Google Scholar 

  41. Patel TV, Singh AK. Kidney disease outcomes quality initiative guidelines for bone and mineral metabolism: emerging questions. Semin Nephrol. 2009;29(2):105–12.

    PubMed  Article  CAS  Google Scholar 

  42. Unger EF, Thompson AM, Blank MJ, Temple R. Erythropoiesis-stimulating agents–time for a reevaluation. N Engl J Med. 2010;362(3):189–92.

    PubMed  Article  CAS  Google Scholar 

  43. K/DOQI. Clinical practice guidelines on hypertension and antihypertensive agents in chronic kidney disease. Am J Kidney Dis. 2004;43(5 Suppl 1):S1–290.

    Google Scholar 

  44. Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report. Jama. 2003;289(19):2560–72.

    PubMed  Article  CAS  Google Scholar 

  45. Appel L, Wright JT, Greene T, et al. Intensive blood-pressure control in hypertensive chronic kidney disease. N Eng J Med. 2010;363(10):918–27.

    Article  CAS  Google Scholar 

  46. Jafar TH, Stark PC, Schmid CH, et al. Progression of chronic kidney disease: the role of blood pressure control, proteinuria, and angiotensin-converting enzyme inhibition: a patient-level meta-analysis. Ann Intern Med. 2003;139(4):244–52.

    PubMed  CAS  Google Scholar 

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Acknowledgements

This study was funded by the Agency for Healthcare Research and Quality (R18 HS018226) and by an Institutional National Research Service Award (T32HP10251-02). We would like to thank Amy Marston and Shimon Shaykevich for their efforts related to data extraction and programming.

Disclosures

Thomas Sequist serves as a consultant on the Aetna Racial and Ethnic Equality External Advisory Committee.

Conflict of Interest

David W. Bates, MD, MSc. is a coinventor on Patent No. 6029138 held by Brigham and Women’s Hospital on the use of decision support software for medical management, licensed to the Medicalis Corporation. He holds a minority equity position in the privately held company Medicalis which develops web-based decision support for radiology test ordering, and has served as a consultant to Medicalis. He is on the clinical advisory board for Zynx, Inc., which develops evidence-based algorithms, and Patient Safety Systems, which provides a set of approaches to help hospitals improve safety. He consults for Hearst, which develops knowledge resources. He serves on the clinical advisory board for SEA Medical Systems, which makes intravenous pump technology. He serves on the board of Care Management International, which is involved in chronic disease management.

Author information

Affiliations

  1. Division of General Medicine, Brigham and Women’s Hospital, Boston, MA, USA

    Adrienne S. Allen MD, E. John Orav PhD, David W. Bates MD, MSc & Thomas D. Sequist MD, MPH

  2. Renal Division, Brigham and Women’s Hospital, Boston, MA, USA

    John P. Forman MD, MSc & Bradley M. Denker MD

  3. Harvard Medical School, Boston, MA, USA

    Adrienne S. Allen MD, John P. Forman MD, MSc, E. John Orav PhD, David W. Bates MD, MSc, Bradley M. Denker MD & Thomas D. Sequist MD, MPH

  4. Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA

    David W. Bates MD, MSc

  5. Harvard Vanguard Medical Associates, Boston, MA, USA

    Adrienne S. Allen MD, John P. Forman MD, MSc, Bradley M. Denker MD & Thomas D. Sequist MD, MPH

Authors
  1. Adrienne S. Allen MD
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  2. John P. Forman MD, MSc
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  3. E. John Orav PhD
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  4. David W. Bates MD, MSc
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  5. Bradley M. Denker MD
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  6. Thomas D. Sequist MD, MPH
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Corresponding author

Correspondence to Adrienne S. Allen MD.

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Allen, A.S., Forman, J.P., Orav, E.J. et al. Primary Care Management of Chronic Kidney Disease. J GEN INTERN MED 26, 386–392 (2011). https://doi.org/10.1007/s11606-010-1523-6

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  • DOI: https://doi.org/10.1007/s11606-010-1523-6

KEY WORDS

  • chronic kidney disease
  • primary care
  • quality of care
  • performance measurement