Trends in Quality of Care for Patients with CKD in the United States

Abstract

Background and objectivesImproving the quality of CKD care has important public health implications to delay disease progression and prevent ESKD. National trends of the quality of CKD care are not well established. Furthermore, it is unknown whether gaps in quality of care are due to lack of physician awareness of CKD status of patients or other factors.Design, setting, participants, & measurementsWe performed a national, serial, cross-sectional study of visits to office-based ambulatory care practices for adults with diagnosed CKD from the years 2006 to 2014. We assessed the following quality indicators: (1) BP measurement, (2) uncontrolled hypertension, (3) uncontrolled diabetes, (4) angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use among patients with hypertension, (5) statin use if age ≥50 years old, and (6) nonsteroidal anti-inflammatory drug use. Using multivariable linear regression and chi-squared analysis, we examined the change in quality performance over time.ResultsBetween 2006 and 2014, there were 7099 unweighted visits for patients with CKD representing 186,961,565 weighted visits. There was no difference in the prevalence of uncontrolled hypertension (>130/80 mm Hg) over time (46% in 2006–2008 versus 48% in 2012–2014; P=0.50). There was a high prevalence of uncontrolled diabetes in 2012–2014 (40% for hemoglobin A1c >7%). The prevalence of ACEi/ARB use decreased from 45% in 2006–2008 to 36% in 2012–2014, which did not reach statistical significance (P=0.07). Statin use in patients with CKD who were 50 years or older was low and remained unchanged from 29% in 2006–2008 to 31% in 2012–2014 (P=0.92).ConclusionsIn a nationally representative dataset, we found that patients with CKD had a high prevalence of uncontrolled hypertension and diabetes and a low use of statins that did not improve over time and was not concordant with guidelines.

Preventing CKD in Developed Countries

“…[61][62][63][64][65] Systematic screening for diabetes, hypertension, and obesity can identify individuals at risk of CKD and permit early diagnosis and intervention to prevent CKD and other comorbidities related to these conditions (Table 1). 61,[66][67][68] A graded risk for CKD exists with diabetes and hypertension, implying some causality and therefore potential for prevention of CKD through reduction in the burdens of hypertension and diabetes. It is clear that reduction of structural and lifestyle-related risks is key to reduce the burdens of diabetes, hypertension, and obesity, and that many population-level interventions are cost-effective over the long term.…”

“…Awareness, Disparities, Capacity, and Barriers to Effective Prevention Despite progress, significant gaps in care remain at the policy, health system, and individual levels across the spectrum of CKD prevention. 61,66,132 The International Society of Nephrology collected data on country-level capacity for kidney care delivery using a survey aligned with the World Health Organization's health system building blocks, and published the findings in the first and second edition of the Global Kidney Health Atlas. 128 This document highlighted limited awareness and prioritization of CKD, as well as persistent inequities in resources required to tackle the burden of kidney disease globally.…”

“…This is a familiar picture demonstrated in similar high-income settings. 66,159 The proliferation of guideline recommendations targeting primary care, however, constitutes a barrier in itself to sustainable implementation of optimal management of chronic diseases including CKD. 66,[159][160][161] For example, an average primary care physician would require about 7-10 hours per working day to follow preventive recommendations for the common chronic diseases.…”

“…66,159 The proliferation of guideline recommendations targeting primary care, however, constitutes a barrier in itself to sustainable implementation of optimal management of chronic diseases including CKD. 66,[159][160][161] For example, an average primary care physician would require about 7-10 hours per working day to follow preventive recommendations for the common chronic diseases. 162,163 Conclusion Prevention of CKD is possible but requires a broad and holistic approach-ranging from good governance and achievement of the sustainable development goals, to ensuring healthy pregnancies for a good start in lifeand access to appropriate screening for early detection and treatment of risk factors for CKD as well as of early CKD ( Figure 2).…”

Combined Albuminuria and Estimated GFR Laboratory Reporting Affects Primary Care Management of CKD

“…Unfortunately, recent assessments of US population-level care for individuals with eGFRs < 60 mL/min/1.73 m 2 reveal that <50% undergo uACR testing, 5 , 6 , 7 only 12% to 20% carry a CKD diagnosis, 6 , 7 almost 50% have hypertension that is not controlled, 6 ∼40% have diabetes that is not controlled, 6 only ∼30% use statins to reduce cardiovascular events, 6 and <40% are using angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs). 6 Although these data predominantly represent primary care delivery, nephrology care has also been suboptimal, with short durations of nephrology services before dialysis initiation and limited preparation for kidney replacement therapy reflected by high rates of hemodialysis catheter use at initiation and low rates of both home dialysis and preemptive kidney transplant. 5 In sum, there is considerable room for improvement in the care of individuals with CKD by primary care clinicians and nephrologists alike.…”