Landelijke Transmurale Afspraak Chronische nierschade

CHANGING NURSING CARE TIME AS AN EFFECT OF CHANGED CHARACTERISTICS OF THE DIALYSIS POPULATION

BACKGROUND

The population of dialysis patients is ageing. Dialysis nurses are confronted with geriatric patients with multiple comorbidities. Nurses are confronted with an increasing burden of care.

OBJECTIVES

The present study focused on the question of whether, over time, the increasing age and comorbidities of the haemodialysis population increased nursing care time. Furthermore, we studied potential changes in the predictors of the required nursing time.

DESIGN

Observational study.

PARTICIPANTS

A total of 980 dialysis patients from 12 dialysis centres were included.

MEASUREMENTS

Nurses filled out the classification tool for each patient and completed a form for reporting patient characteristics for groups of relevant haemodialysis patients at baseline and after 1 and four years. Changes in patient and dialysis characteristics were analysed, as well as the estimated nursing care time needed.

RESULTS

An increase in the nursing time needed for dialysis was largely due to decreased mobility, closing of the vascular access and a greater need for psychosocial attention and was most strongly present in incident dialysis patients. The time needed for dialysis decreased as patient participation increased and vascular access changed from catheters to fistulae. Over the four-year period, the average overall needed nursing care time per haemodialysis session did not change.

CONCLUSIONS

Our study shows that the average nursing time needed per patient did not change in the four-year observation period. However, more time is required for incident patients; thus, if a centre has high patient turnover, more nursing care time is needed.

Longitudinal follow-up of kidney function in patients with a history of preeclampsia: From 11 to 18 years postpartum

Formerly preeclamptic (fPE) women are reported to have an increased risk to develop end stage kidney disease. To gain more insight in the course of kidney function after preeclampsia we assessed blood pressure, eGFR and urinary protein loss in 75 fPE women at 11 and 18 years postpartum. We found that during follow-up blood pressure did not increase and no cases of CKD were identified. Only a small decrease in eGFR (6-7 mL/min) and a small increase in urinary protein loss were observed, which fall within the expected range of normal aging. In conclusion, our data suggests that progression to kidney disease might not be a major concern in women after preeclampsia within 18 years postpartum.

Guidelines and clinical practice at the primary level of healthcare in patients with type 2 diabetes mellitus with and without kidney disease in five European countries

BACKGROUND

The number of patients with type 2 diabetes mellitus and diabetes mellitus-associated chronic kidney disease varies considerably between countries. Next to differences in genetic as well as life style risk factors, varying practices in medical care delivery might cause this diversity.

METHOD

The PROVALID study recruited 4000 patients with type 2 diabetes mellitus at the primary level of healthcare in five European countries (Austria, Hungary, The Netherlands, Poland and Scotland). Baseline data were used to describe patient characteristics and compare the adherence to ADA (American Diabetes Association) and KDIGO (Kidney Disease: Improving Global Outcomes) guidelines with respect to metabolic and blood pressure control, use of renin-angiotensin system-blocking agents, statins and acetylsalicylic acid between the countries.

RESULTS

About 34.8% of the population had evidence of diabetes mellitus-associated chronic kidney disease. The median HbA1c level of the cohort was 6.8% (ranging from 6.5 in Poland to 7.0% in Scotland). Mean blood pressure was 136/79 (±17/10) and significantly higher in subjects with elevated albuminuria. These individuals also were more often treated with renin-angiotensin system-blocking agents (74.1% vs 84.6%), whereas the use of statins was driven by cardiovascular comorbidity. Acetylsalicylic acid was used in only 28.9% subjects. Despite similar cardiovascular comorbidities and renal function, the use of renin-angiotensin system-blocking agents varied significantly between the countries from 66.7% to 87.4%. An even higher variability was observed for patients >40 years of age using statins (39.8%-82.7%) and administration of acetylsalicylic acid in patients older than 50 years (5.2%-43.8%).

CONCLUSION

Our study shows that medical practice in type 2 diabetes mellitus patients with and without renal disease is different in European countries. Longitudinal follow-up will reveal if this diversity affects clinical endpoints.

General practitioners' perspectives on management of early-stage chronic kidney disease: a focus group study

BACKGROUND

Guideline adherence in chronic kidney disease management is low, despite guideline implementation initiatives. Knowing general practitioners' (GPs') perspectives of management of early-stage chronic kidney disease (CKD) and the applicability of the national interdisciplinary guideline could support strategies to improve quality of care.

METHOD

Qualitative focus group study with 27 GPs in the Netherlands. Three analysts open-coded and comparatively analysed the data. Mind-mapping sessions were performed after data-saturation.

RESULTS

Five themes emerged: defining CKD, knowledge and awareness, patient-physician interaction, organisation of CKD care and value of the guideline. A key finding was the abstractness of the CKD concept. The GPs expressed various perspectives about defining CKD and interpreting estimated glomerular filtration rates. Views about clinical relevance influenced the decision-making, although factual knowledge seems lacking. Striving to inform well enough without creating anxiety and to explain suitably for the intellectual ability of the patient caused tension in the patient-physician interaction. Integration with cardiovascular disease-management programmes was mentioned as a way of implementing CKD care in the future. The guideline was perceived as a rough guide rather than a leading document.

CONCLUSION

CKD is perceived as an abstract rather than a clinical concept. Abstractness plays a role in all formulated themes. Management of CKD patients in primary care is complex and is influenced by physician-bound considerations related to individual knowledge and perception of the importance of CKD. Strategies are needed to improve GPs' understanding of the concept of CKD by education, a holistic approach to guidelines, and integration of CKD care into cardiovascular programmes.

TRIAL REGISTRATION

Not applicable.

Web-based consultation between general practitioners and nephrologists: a cluster randomized controlled trial

BACKGROUND

Consultation of a nephrologist is important in aligning care for patients with chronic kidney disease (CKD) at the primary-secondary care interface. However, current consultation methods come with practical difficulties that can lead to postponed consultation or patient referral instead.

OBJECTIVE

This study aimed to investigate whether a web-based consultation platform, telenephrology, led to a lower referral rate of indicated patients. Furthermore, we assessed consultation rate, quality of care, costs and general practitioner (GPs') experiences with telenephrology.

METHODS

Cluster randomized controlled trial with 47 general practices in the Netherlands was randomized to access to telenephrology or to enhanced usual care. A total of 3004 CKD patients aged 18 years or older who were under primary care were included (intervention group n = 1277, control group n = 1727) and 2693 completed the trial. All practices participated in a CKD management course and were given an overview of their CKD patients.

RESULTS

The referral rates amounted to 2.3% (n = 29) in the intervention group and 3.0% (n = 52) in the control group, which was a non-significant difference, OR 0.61; 95% CI 0.31 to 1.23. The intervention group's consultation rate was 6.3% (n = 81) against 5.0% (n = 87) (OR 2.00; 95% CI 0.75-5.33). We found no difference in quality of care or costs. The majority of GPs had a positive opinion about telenephrology.

CONCLUSION

The data in our study do not allow for conclusions on the effect of telenephrology on the rate of patient referrals and provider-to-provider consultations, compared to conventional methods. It was positively evaluated by GPs and was non-inferior in terms of quality of care and costs.

Adherence to chronic kidney disease guidelines in primary care patients is associated with comorbidity

BACKGROUND

GPs insufficiently follow guidelines regarding consultation and referral for chronic kidney disease (CKD).

OBJECTIVE

To identify patient characteristics and quality of care (QoC) in CKD patients with whom consultation and referral recommendations were not followed.

METHOD

A 14 month prospective observational cohort study of primary care patients with CKD stage 3-5. 47 practices participated, serving 207469 people. 2547 CKD patients fulfilled consultation criteria, 225 fulfilled referral criteria. We compared characteristics of patients managed by GPs with patients receiving nephrologist co-management. We assessed QoC as adherence to monitoring criteria, CKD recognition and achievement of blood pressure (BP) targets.

RESULTS

Patients treated in primary care despite a consultation recommendation (94%) had higher eGFR values (OR 1.07; 95% CI: 1.05-1.09), were less often monitored for renal function (OR 0.42; 95% CI: 0.24-0.74) and potassium (OR 0.56; 95% CI: 0.35-0.92) and CKD was less frequently recognised (OR 0.46; 95% CI: 0.31-0.68) than in patients with nephrologist co-management. Patients treated in primary care despite referral recommendation (70%) were older (OR 1.03; 95% CI:1.01-1.06) and had less cardiovascular disease (OR 0.37; 95% CI: 0.19-0.73). Overall, in patients solely managed by GPs, CKD recognition was 50%, monitoring disease progression in 36% and metabolic parameters in 3%, BP targets were achieved in 51%. Monitoring of renal function and BP was positively associated with diabetes (OR 3.10; 95% CI: 2.47-3.88 and OR 7.78; 95% CI: 3.21-18.87) and hypertension (OR 3.19; 95% CI: 2.67-3.82 and OR 3.35; 95% CI: 1.45-7.77).

CONCLUSION

Patients remaining in primary care despite nephrologists' co-management recommendations were inadequately monitored, and BP targets were insufficiently met. CKD patients without cardiovascular comorbidity or diabetes require extra attention to guarantee adequate monitoring of renal function and BP.

Development and validation of prescribing quality indicators for patients with type 2 diabetes

AIM

Quality indicators are used to measure whether healthcare professionals act according to guidelines, but few indicators focus on the quality of pharmacotherapy for diabetes. The aim of this study was to develop and validate a set of prescribing quality indicators (PQIs) for type 2 diabetes in primary care, and to apply this set in practice. To take into account the stepwise treatment of chronic disease, clinical action indicators were specifically considered.

METHODS

Potential PQIs were derived from clinical practice guidelines and evaluated using the RAND/UCLA Appropriateness Method, a modified Delphi panel. Thereafter, the feasibility of calculating the PQIs was tested in two large Dutch primary care databases including >80 000 diabetes patients in 2012.

RESULTS

32 PQIs focusing on treatment with glucose, lipid, blood pressure and albuminuria lowering drugs, and on vaccination, medication safety and adherence were assessed by ten experts. After the Delphi panel, the final list of twenty PQIs was tested for feasibility. All PQIs definitions were feasible for measuring the quality of medication treatment using these databases. Indicator scores ranged from 18.8% to 90.8% for PQIs focusing on current medication use, clinical action and medication choice, and from 2.1% to 37.2% for PQIs focusing on medication safety.

DISCUSSION AND CONCLUSIONS

Twenty PQIs focusing on treatment with glucose, lipid, blood pressure and albuminuria lowering drugs, and on medication safety in type 2 diabetes were developed, considered valid and operationally feasible. Results showed room for improvement, especially in initiation and intensification of treatment as measured with clinical action indicators.

Medication management strategy for older people with polypharmacy in general practice: a qualitative study on prescribing behaviour in primary care

BACKGROUND

For older patients with polypharmacy, medication management is a process of careful deliberation that needs periodic adjustment based on treatment effects and changing conditions. Because of the heterogeneity of the patient group, and limited applicability of current guidelines, it is difficult for GPs to build up a routine.

AIM

To gain insight into GPs' medication management strategies for patients with polypharmacy, and to explore the GPs' perspectives and needs on decision-making support to facilitate this medication management.

DESIGN AND SETTING

Two focus group meetings with Dutch GPs, discussing four clinical vignettes of patients with multimorbidity and polypharmacy.

METHOD

Questions about medication management of the vignettes were answered individually; the strategy chosen in each case was discussed in plenary. Analysis followed a Framework approach.

RESULTS

In total, 12 GPs described a similar strategy regarding the patients' medication management: defining treatment goals; determining primary goals; and adjusting medications based on the treatment effect, GPs' and patients' preferences, and patient characteristics. There was variation in the execution of this strategy between the GPs. The GPs would like to discuss their choices with other professionals and they valued structured medication reviews with the patient, as well as quick and practical support tools that work on demand.

CONCLUSION

To facilitate decision making, a more extensive and structured collaboration between healthcare professionals is desired, as well as support to execute structured medication reviews with eligible patients, and some on-demand tools for individual consultations.

Development and initial validation of prescribing quality indicators for patients with chronic kidney disease

BACKGROUND

Quality assessment is a key element for improving the quality of care. Currently, a comprehensive indicator set for measuring the quality of medication treatment in patients with chronic kidney disease (CKD) is lacking. Our aim was to develop and validate a set of prescribing quality indicators (PQIs) for CKD care, and to test the feasibility of applying this set in practice.

METHODS

Potential indicators were based on clinical practice guidelines and evaluated using the RAND/UCLA Appropriateness Method. This is a structured process in which an expert panel assesses the validity of the indicators. Feasibility was tested in a Dutch primary care database including >4500 diabetes patients with CKD.

RESULTS

An initial list of 22 PQIs was assessed by 12 experts. After changing 10 PQIs, adding 2 and rejecting 8, a final list of 16 indicators was accepted by the expert panel as valid. These PQIs focused on the treatment of hypertension, albuminuria, mineral and bone disorder, statin prescribing and possible unsafe medication. The indicators were successfully applied to measure treatment quality in the primary care database, but for some indicators the number of eligible patients was too small for reliable calculation. Results showed that there was room for improvement in the treatment quality of this population.

CONCLUSIONS

We developed a set of 16 PQIs for measuring the quality of treatment in CKD patients, which had sufficient content and face validity as well as operational feasibility. These PQIs can be used to point out priority areas for improvement.

Quality of chronic kidney disease management in primary care: a retrospective study

BACKGROUND

Early detection and appropriate management of chronic kidney disease (CKD) in primary care are essential to reduce morbidity and mortality.

AIM

To assess the quality of care (QoC) of CKD in primary healthcare in relation to patient and practice characteristics in order to tailor improvement strategies.

DESIGN AND SETTING

Retrospective study using data between 2008 and 2011 from 47 general practices (207 469 patients of whom 162 562 were adults).

METHOD

CKD management of patients under the care of their general practitioner (GP) was qualified using indicators derived from the Dutch interdisciplinary CKD guideline for primary care and nephrology and included (1) monitoring of renal function, albuminuria, blood pressure, and glucose, (2) monitoring of metabolic parameters, and alongside the guideline: (3) recognition of CKD. The outcome indicator was (4) achieving blood pressure targets. Multilevel logistic regression analysis was applied to identify associated patient and practice characteristics.

RESULTS

Kidney function or albuminuria data were available for 59 728 adult patients; 9288 patients had CKD, of whom 8794 were under GP care. Monitoring of disease progression was complete in 42% of CKD patients, monitoring of metabolic parameters in 2%, and blood pressure target was reached in 43.1%. GPs documented CKD in 31.4% of CKD patients. High QoC was strongly associated with diabetes, and to a lesser extent with hypertension and male sex.

CONCLUSION

Room for improvement was found in all aspects of CKD management. As QoC was higher in patients who received structured diabetes care, future CKD care may profit from more structured primary care management, e.g. according to the chronic care model.

KEY POINTS

Quality of care for chronic kidney disease patients in primary care can be improved. In comparison with guideline advice, adequate monitoring of disease progression was observed in 42%, of metabolic parameters in 2%, correct recognition of impaired renal function in 31%, and reaching blood pressure targets in 43% of chronic kidney disease patients. Quality of care was higher in patients with diabetes. Chronic kidney disease management may be improved by developing strategies similar to diabetes care.

Cobalamin status and its relation with depression, cognition and neuropathy in patients with type 2 diabetes mellitus using metformin

AIMS

To investigate the associations of vitamin B12 (cobalamin and holotranscobalamin) status with depression, cognition and neuropathy in patients with type 2 diabetes using metformin.

METHODS

In an observational study, among 550 type 2 diabetes patients using metformin, cobalamin and holotranscobalamin (holoTCII) levels were measured at the annual diabetes checkup, and deficiencies were defined as <148 and <21 pmol/L, respectively. Depression and cognitive function were assessed with corresponding International Classification of Primary Care codes and questionnaires; neuropathy with medical record data and a questionnaire. Confounding variables were retrieved from medical records. Multivariable logistic and linear regressions were used with cobalamin status as independent variable; depression, cognition and neuropathy as dependent variables.

RESULTS

The mean duration of diabetes was 8.4 years (±5.8); mean duration of metformin use was 64.1 months (±43.2), with a mean metformin dose of 1,306 mg/day. A sufficient cobalamin level was independently associated with a decreased risk of depression (OR 0.42; 95 % CI 0.23-0.78) and better cognitive performance (β = 1.79; 95 % CI 0.07-3.52) adjusted for confounders. This indicates that cobalamin-deficient patients had a 2.4 times higher chance of depression and a 1.79 point lower cognitive performance score. HoloTCII was not associated with any outcome.

CONCLUSIONS

Cobalamin deficiency was associated with an increased risk of depression and worse cognitive performance, while holoTCII was not. Screening for cobalamin deficiency may be warranted in diabetes patients using metformin. Physicians should consider a cobalamin deficiency in diabetes patients using metformin with a depression or cognitive decline.

Ischaemic cardiovascular risk and prescription of non-steroidal anti-inflammatory drugs for musculoskeletal complaints

OBJECTIVE

To determine the influence of ischaemic cardiovascular (CV) risk on prescription of non-steroidal anti-inflammatory drugs (NSAIDs) by general practitioners (GPs) in patients with musculoskeletal complaints.

DESIGN

Cohort study.

SETTING

A healthcare database containing the electronic GP medical records of over one million patients throughout the Netherlands.

PATIENTS

A total of 474 201 adults consulting their GP with a new musculoskeletal complaint between 2000 and 2010. Patients were considered at high CV risk if they had a history of myocardial infarction, angina pectoris, stroke, transient ischaemic attack, or peripheral arterial disease, and at low CV risk if they had no CV risk factors.

MAIN OUTCOME MEASURES

Frequency of prescription of non-selective (ns)NSAIDs and selective cyclooxygenase-2 inhibitors (coxibs).

RESULTS

Overall, 24.4% of patients were prescribed an nsNSAID and 1.4% a coxib. Of the 41,483 patients with a high CV risk, 19.9% received an nsNSAID and 2.2% a coxib. These patients were more likely to be prescribed a coxib than patients with a low CV risk (OR 1.9, 95% CI 1.8-2.0). Prescription of nsNSAIDs decreased over time in all risk groups and was lower in patients with a high CV risk than in patients with a low CV risk (OR 0.8, 95% CI 0.7-0.8).

CONCLUSION

Overall, patients with a high CV risk were less likely to be prescribed an NSAID for musculoskeletal complaints than patients with a low CV risk. Nevertheless, one in five high CV risk patients received an NSAID, indicating that there is still room for improvement.

High-risk use of over-the-counter non-steroidal anti-inflammatory drugs: a population-based cross-sectional study

BACKGROUND

The use of non-steroidal anti-inflammatory drugs (NSAIDs) is associated with serious adverse drug events (ADEs).

AIM

To determine the prevalence of over-the-counter (OTC) NSAID use in the general population and in patients with a high risk of developing a serious NSAID-related ADE.

DESIGN AND SETTING

Cross-sectional study in four general practices in the Netherlands.

METHOD

Two patient samples were selected: a random sample of adults (general population sample); and adult patients with a high risk of developing a serious ADE in case of NSAID use (high-risk sample). All included patients were sent a questionnaire regarding their use of OTC NSAIDs in the 4 weeks prior to participation.

RESULTS

In the general population sample, 118 of 456 (26%) invited patients completed the questionnaire. Of these, 35 (30%) had used an OTC NSAID. In the high-risk sample, 264 of 713 (37%) invited patients completed the questionnaire, and of these high-risk patients 33 (13%) had used an OTC NSAID. Over 20% of OTC NSAID users in the general population sample and over 30% in the high-risk sample had used the OTC NSAID for >7 days. OTC NSAIDs were used in a dosage exceeding the recommended daily maximum by 9% and 3% of OTC NSAID users in the general population and the high-risk sample respectively.

CONCLUSION

OTC NSAIDs are used by almost one-third of the general population. In the high-risk patients selected, one in eight patients used an OTC NSAID. Continued efforts by health authorities and healthcare professionals to inform patients of the risks of these drugs are warranted.

The longitudinal association between depressive symptoms and initiation of insulin therapy in people with type 2 diabetes in primary care

Objective

To examine whether depressive symptoms are associated with time to insulin initiation in insulin-naïve people with type 2 diabetes in primary care.

Methods

1,389 participants completed the Edinburgh Depression Scale (EDS) in 2005 and were followed until: 1) insulin therapy was started, 2) death, 3) an oral antihyperglycemic drug (OAD) prescription gap >1 year, 4) last OAD prescription in 2010 or 5) the end of the study (December 31, 2010). Cox regression analyses were used to determine whether there was a difference in time to insulin initiation between people with a low versus a high depression score at baseline, adjusting for potential demographic and clinical confounders, including HbA_1c levels.

Results

The prevalence of depression (EDS≥12) was 12% (n = 168). After a mean follow-up of 1,597±537 days, 253 (18%) participants had started insulin therapy. The rate of insulin initiation did not differ between depressed and non-depressed participants. People with depression were not more likely to start insulin therapy earlier or later than their non-depressed counterparts (HR = 0.98, 95% CI 0.66–1.45), also after adjustment for sex and age (HR = 0.95, 0.64–1.42). The association remained non-significant when individual candidate confounders were added to the age- and sex-adjusted base model.

Conclusions

In the present study, depression was not associated with time to insulin initiation. The hypothesis that depression is associated with delayed initiation of insulin therapy merits more thorough testing, preferably in studies where more information is available about patient-, provider- and health care system factors that may influence the decision to initiate insulin.

The course of depressive symptoms in primary care patients with type 2 diabetes: results from the Diabetes, Depression, Type D Personality Zuidoost-Brabant (DiaDDZoB) Study

AIMS/HYPOTHESIS

The aim of the study was to examine the course (incidence, recurrence/persistence) of depressive symptoms in primary care patients with type 2 diabetes and to identify significant predictors of these different course patterns.

METHODS

A cohort of 2,460 primary care patients with type 2 diabetes was assessed for demographic, clinical and psychological factors in 2005 and followed-up in 2007 and 2008. Depression was defined as a score of ≥ 12 on the Edinburgh Depression Scale. Multivariate logistic regression analyses were used to determine whether several depression-course patterns could be predicted by means of demographics, medical co-morbidities and psychological factors.

RESULTS

A total of 630 patients (26%) met the criterion for depression at one or more assessments. In the subgroup with no baseline depression, incident depression at follow-up was present in 14% (n = 310), while recurrence/persistence in those with baseline depression was found in 66% (n = 212).The presence of any depression was associated with being female, low education, non-cardiovascular chronic diseases, stressful life events and a self-reported history of depression. Incident depression was predicted by female sex, low education and depression history, while patients with a history of depression had a 2.5-fold increased odds of recurrent/persistent depression.

CONCLUSIONS/INTERPRETATION

Depression is common in primary care patients with type 2 diabetes, with one in seven patients reporting incident depression during a 2.5 year period. Once present, depression often becomes a chronic/recurrent condition in this group. In order to identify patients who are vulnerable to depression, clinicians can use questionnaire data and/or information about the history of depression.