Documentation and Management of CKD in Rural Primary Care

Abstract

SummaryBackground and objectives Recognition of CKD by primary care practitioners is essential in rural communities where nephrology access is limited. This study determined the prevalence of undocumented CKD in patients cared for in rural primary care practices and evaluated characteristics associated with undocumented CKD as well as CKD management.Design, setting, participants, & measurements A retrospective cohort study, conducted within the Oregon Rural Practice Based Research Network, consisted of 865 CKD patients with serum creatinine$1.5 mg/dl in males and $1.3 mg/dl in females and an estimated GFR,60 ml/min per 1.73 m 2 . Documentation of a CKD diagnosis and laboratory values were abstracted by chart review.Results Of CKD patients, 51.9% had no documentation of CKD. Undocumented CKD occurred more frequently in female patients (adjusted odds ratio=2.93, 95% confidence interval=2.04, 4.21). The association of serum creatinine reporting versus automating reporting of estimated GFR on CKD documentation was dependent on patient sex, years of practitioner experience, and practitioner clinical training. Hypertensive patients with documented CKD were more likely to have a BP medication change than patients with undocumented CKD (odds ratio=2.07, 95% confidence interval=1.15, 3.73). Only 2 of 449 patients with undocumented CKD were comanaged with a nephrologist compared with 20% of patients with documented CKD (odds ratio=53.20, 95% confidence interval=14.90, 189.90).Conclusions Undocumented CKD in a rural primary care setting is frequent, particularly in female patients. Depending on practitioner characteristics, automatic reporting of estimated GFR might improve documentation of CKD in this population.

Chronic Kidney Disease in an Electronic Health Record Problem List: Quality of Care, ESRD, and Mortality

“…23 Through chart review of nearly 900 patients with an eGFR < 60 being cared for in rural practices a study found less than 50% with documented CKD, even among those with high risk conditions such as hypertension and diabetes. 24 Similar to our finding of increased recognition with advanced CKD, a PCP practice based research network with nearly 35,000 CKD patients, found very low documentation of diagnosis among early CKD eGFR 45–59 (<10%), but higher documentation among CKD eGFR 30–44 (54%) and eGFR15-29 (54%). 25 Unlike our study, they did not report processes of care nor ESRD or mortality rates.…”

The Utility of a National Surveillance Network to Estimate CKD Prevalence and Identify High-Risk Populations in Primary Care

“…The increased CKD prevalence described in this group is concerning, given data showing that CKD care in the rural population is suboptimal. In a cohort of CKD patients cared for in rural primary care practices in the United States, 51.9% had no documentation of CKD in their medical record 6 . Undocumented CKD was highly associated with not being referred to a nephrologist.…”

Chronic Kidney Disease Care in the US Safety Net

“…50 Despite these improvements, however, identification of CKD remains suboptimal, suggesting that other approaches are needed. Disease registries, which are information platforms that enhance chronic disease management through targeted alerts, have been piloted in numerous systems across the United States to enhance health outcomes among complex patients.…”