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Primary Care Management of Chronic Kidney Disease

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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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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.

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Authors and 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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  6. Thomas D. Sequist MD, MPH
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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

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