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Almaqhawi A. Knowledge and Competence Regarding the Management of Chronic Kidney Disease among Family Medicine Professionals in the Eastern Province of Saudi Arabia: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:880. [PMID: 39063457 PMCID: PMC11276965 DOI: 10.3390/ijerph21070880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 06/17/2024] [Accepted: 06/26/2024] [Indexed: 07/28/2024]
Abstract
Diabetes is a significant risk factor for chronic kidney disease (CKD) and a primary cause of global morbidity and mortality, resulting in significant costs to healthcare systems. The management of diabetic CKD in the primary care setting remains an ongoing challenge despite the current best practices in the quality of care. This study evaluated family medicine physicians' knowledge and confidence regarding managing CKD in the Eastern Province of Saudi Arabia. A self-administered online questionnaire was distributed to physicians through various social media sites and email lists. The largest number of participants reported a full confidence in knowing kidney disease stages, blood pressure targets and the importance of urine albumin-creatinine ratio testing. Overall, 71.8% of physicians reported a high confidence level, followed by 23.9% reporting average and 4.2% reporting low confidence. Being younger and working at PHC were identified as significant predictors of increased confidence. Although most of the physicians reported a high confidence in managing CKD patients, the need for improvement was evident. Age and workplace institutions were the greater contributors to physicians' confidence. Continuous education among healthcare practitioners is crucial to updating knowledge and providing optimum quality of care among this group of patients.
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Affiliation(s)
- Abdullah Almaqhawi
- Department of Family and Community Medicine, College of Medicine, King Faisal University, Al Hofuf P.O. Box 400, Saudi Arabia
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2
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Jhamb M, Weltman MR, Devaraj SM, Lavenburg LMU, Han Z, Alghwiri AA, Fischer GS, Rollman BL, Nolin TD, Yabes JG. Electronic Health Record Population Health Management for Chronic Kidney Disease Care: A Cluster Randomized Clinical Trial. JAMA Intern Med 2024; 184:737-747. [PMID: 38619824 PMCID: PMC11019443 DOI: 10.1001/jamainternmed.2024.0708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 02/12/2024] [Indexed: 04/16/2024]
Abstract
Importance Large gaps in clinical care in patients with chronic kidney disease (CKD) lead to poor outcomes. Objective To compare the effectiveness of an electronic health record-based population health management intervention vs usual care for reducing CKD progression and improving evidence-based care in high-risk CKD. Design, Setting, and Participants The Kidney Coordinated Health Management Partnership (Kidney CHAMP) was a pragmatic cluster randomized clinical trial conducted between May 2019 and July 2022 in 101 primary care practices in Western Pennsylvania. It included patients aged 18 to 85 years with an estimated glomerular filtration rate (eGFR) of less than 60 mL/min/1.73m2 with high risk of CKD progression and no outpatient nephrology encounter within the previous 12 months. Interventions Multifaceted intervention for CKD comanagement with primary care clinicians included a nephrology electronic consultation, pharmacist-led medication management, and CKD education for patients. The usual care group received CKD care from primary care clinicians as usual. Main Outcomes and Measures The primary outcome was time to 40% or greater reduction in eGFR or end-stage kidney disease. Results Among 1596 patients (754 intervention [47.2%]; 842 control [52.8%]) with a mean (SD) age of 74 (9) years, 928 (58%) were female, 127 (8%) were Black, 9 (0.6%) were Hispanic, and the mean (SD) estimated glomerular filtration rate was 36.8 (7.9) mL/min/1.73m2. Over a median follow-up of 17.0 months, there was no significant difference in rate of primary outcome between the 2 arms (adjusted hazard ratio, 0.96; 95% CI, 0.67-1.38; P = .82). Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker exposure was more frequent in intervention arm compared with the control group (rate ratio, 1.21; 95% CI, 1.02-1.43). There was no difference in the secondary outcomes of hypertension control and exposure to unsafe medications or adverse events between the arms. Several COVID-19-related issues contributed to null findings in the study. Conclusion and Relevance In this study, among patients with moderate-risk to high-risk CKD, a multifaceted electronic health record-based population health management intervention resulted in more exposure days to angiotensin-converting enzyme inhibitors/angiotensin receptor blockers but did not reduce risk of CKD progression or hypertension control vs usual care. Trial Registration ClinicalTrials.gov Identifier: NCT03832595.
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Affiliation(s)
- Manisha Jhamb
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Melanie R. Weltman
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Susan M. Devaraj
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Linda-Marie Ustaris Lavenburg
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Zhuoheng Han
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Alaa A. Alghwiri
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Gary S. Fischer
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Bruce L. Rollman
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Center for Behavioral Health, Media, and Technology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Thomas D. Nolin
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Jonathan G. Yabes
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Center for Research on Heath Care, Division of General Internal Medicine, Department of Medicine and Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
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Al-Zaman N, Alem A, Alharbi OA, Ahmed Abdullah E, Azouni DW, Hammad RK, Alhejaily RM, Albadrani M. Physicians' Knowledge, Attitudes and Barriers Regarding Chronic Kidney Disease Diagnosis and Management in Saudi Arabia. Cureus 2023; 15:e50247. [PMID: 38196437 PMCID: PMC10774705 DOI: 10.7759/cureus.50247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is defined as abnormalities of kidney structure and/or function persisting for a minimum of three months. METHODS An online cross-sectional study was conducted in the Kingdom of Saudi Arabia (KSA) between June and August 2022 to assess the knowledge, attitudes, practices, and barriers among family, internal medicine, and general physicians related to CKD screening, diagnosis, and management. RESULTS A total of 427 physicians were included in the study. The majority exhibited a strong grasp of the accurate definition of CKD (83%) and recognized common risk factors, such as diabetes (99%), drugs (95%), and hypertension (98%). Two-thirds of physicians were aware of the five stages of CKD and identified estimated glomerular filtration rate (eGFR) and creatinine clearance as the most suitable markers for kidney function. Physicians also displayed knowledge of CKD-related complications. However, a noticeable gap between knowledge and practice was evident. Only one-third of participants reported screening their patients every year, primarily using serum creatinine (92.5%) and eGFR (97%) for diagnosis, while only 16% recognized that stage 4 CKD is the appropriate time to refer patients to nephrologists. In terms of barriers, the majority of physicians reported encountering low barriers to CKD management, but general practitioners working in primary healthcare centers experienced significantly higher levels of barriers. CONCLUSION Most participants in our study possess a good level of knowledge and positive attitudes towards CKD diagnosis and management. Nevertheless, a discrepancy between knowledge and practical application, particularly in terms of over-screening and early referral, highlights the need for educational efforts to improve physician practice in KSA. These findings underscore the importance of addressing this gap to promote effective CKD management.
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Affiliation(s)
- Naweed Al-Zaman
- Internal Medicine, College of Medicine, Taibah University, Medina, SAU
| | - Alaa Alem
- Internal Medicine, College of Medicine, Taibah University, Medina, SAU
| | - Ohood A Alharbi
- Medicine, College of Medicine, Taibah University, Medina, SAU
| | | | - Duha W Azouni
- Medicine, College of Medicine, Taibah University, Medina, SAU
| | - Raghad K Hammad
- Medicine, College of Medicine, Taibah University, Medina, SAU
| | | | - Muayad Albadrani
- Family and Community Medicine, College of Medicine, Taibah University, Medina, SAU
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Seidu S, Cos X, Topsever P. Self-rated knowledge and competence regarding the management of chronic kidney disease in primary care: A cross-sectional European survey of primary care professionals. Prim Care Diabetes 2023; 17:19-26. [PMID: 36513582 DOI: 10.1016/j.pcd.2022.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 11/16/2022] [Accepted: 11/29/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Diabetes is a major risk factor for chronic kidney disease (CKD), which is a leading cause of global morbidity and mortality and also associated with substantial costs to healthcare systems. Despite the current best practice standards of care, management of CKD in diabetes in the primary care setting remains an ongoing challenge. Using an online survey, we aimed to assess the self-rated knowledge and competence of primary care professionals involved in the management of CKD in diabetes in the European region. METHODS An online anonymous survey was developed by the Primary Care Diabetes Europe research group and administered to primary care professionals involved in managing CKD in diabetes from 23rd March 2022-9 th October 2022. Descriptive statistics were used to summarise questionnaire responses. Factors influencing ability to initiate treatment strategies were evaluated using logistic regression. RESULTS A total of 266 respondents (51.9% males) completed the questionnaire. Most respondents were GPs (82.7%) followed by nurses (9.4%). The age of respondents ranged from 25 to 72 years with a median of 51 years. About a third of respondents indicated that they were fully confident in the screening and diagnosis of CKD in diabetes. With regards to CKD presentation, staging and prognosis, 16.5-21.8% of respondents stated they were fully confident in this area; however, about 11% of respondents were not confident on how to predict CKD prognosis using established clinical guidelines. About a third of respondents stated they were confident without support regarding the complications of kidney disease in diabetes and it being a risk multiplier; just a quarter of respondents were fully confident. A third of respondents stated they were fully confident regarding appropriate management strategies for preventing or slowing down the progression of CKD and the initiation of newer agents. In multivariable analyses, confidence in the knowledge of the stages of kidney disease and criteria for the diagnosis of kidney disease were each associated with an increased odds in the confidence to select and initiate appropriate management strategies. CONCLUSIONS With regards to almost all aspects of management of CKD in diabetes, only up to a third of primary care professionals stated they are fully confident and are able to teach others; the majority are confident but would like to know more or require extra support. This may be a contributor to the challenges faced in providing optimal CKD care in people with diabetes in the primary care setting. Effective interventions that can promote the uptake of best practice clinical guidelines in primary care are urgently needed.
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Affiliation(s)
- Samuel Seidu
- Leicester Diabetes Centre, Leicester General Hospital, Gwendolen Road, Leicester LE5 4WP, UK; Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4WP, UK.
| | - Xavier Cos
- The Foundation University Institute for Primary Health Care Research Jordi Gol i Gurina (IDIAPJGol), Spain
| | - Pinar Topsever
- Acibadem Mehmet Ali Aydinlar University School of Medicine Department of Family Medicine, Kerem Aydinlar Campus, Kayisdagi Cad. No 32, 34752 Atasehir, Istanbul, Turkey
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Jazienicka-Kiełb A, Babicki M, Krajewska M, Oko A, Kłoda K, Mastalerz-Migas A. Assessment of primary care physicians' knowledge of chronic kidney disease in Poland. Front Public Health 2022; 10:1032240. [PMID: 36339213 PMCID: PMC9631929 DOI: 10.3389/fpubh.2022.1032240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/05/2022] [Indexed: 01/29/2023] Open
Abstract
Chronic kidney disease (CKD) affects 10-15% of the adult population worldwide and is a major societal problem. A latent course of the disease and little alarming, gradually increasing symptoms usually do not cause concern in patients and diagnostic vigilance in physicians. CKD is most often diagnosed in its end-stage when treatment options are extremely limited. This study aims to assess the knowledge of CKD among primary care physicians (PCPs) in Poland. A CAWI survey was conducted based on an authors' own questionnaire that consisted of two parts. The first part concerned patients' socioeconomic data while the second part consisted of nine single- and multiple-choice questions assessing knowledge of the criterion for diagnosis, risk factors, diagnostic evaluation, and course of CKD. A total of 610 physicians took part in the survey, including 502 (82.3%) who fully completed the questionnaire. Women accounted for 83.1% of the study group. The mean age of the study group was 37.4 ± 10.1 years. Specialists or resident physicians in family medicine accounted for 79.9% of respondents and 93.8% of physicians are those who mainly work in primary care settings. In the knowledge test, the mean score obtained by physicians was 6.5 ± 1.3 out of possible 9, with only 2.4% of respondents answering all questions correctly. According to the survey, 78.4% of respondents correctly indicated the criterion for the diagnosis of CKD, while only 68.9% identified a test for increased urinary albumin loss as the one of the greatest diagnostic values in the early stages of CKD. More than half, 63.1%, of physicians selected the correct set of answers in the multiple-choice question regarding CKD risk factors. Despite a fairly high level of knowledge among family medicine physicians regarding the causes, risk factors and course of CKD, there is a need for further education and an increase in the factual information held by this professional group, especially that the vast majority of PCPs declare a desire to expand their knowledge and believe that this will help them in their daily clinical practice.
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Affiliation(s)
| | - Mateusz Babicki
- Department of Family Medicine, Wroclaw Medical University, Wrocław, Poland,*Correspondence: Mateusz Babicki
| | - Magdalena Krajewska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wrocław, Poland
| | - Andrzej Oko
- Department of Nephrology, Transplantology and Internal Diseases, Poznan University of Medical Sciences, Poznan, Poland
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Tan WB, Szücs A, Burkill SM, Hui OS, Young D, Hoon GL. Nephrologist referrals of older patients with chronic kidney disease in Singapore: a cross-sectional study. BJGP Open 2022; 6:BJGPO.2021.0155. [PMID: 35288445 PMCID: PMC9680736 DOI: 10.3399/bjgpo.2021.0155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 01/08/2022] [Accepted: 03/08/2022] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is common in the older population. By 2035, approximately one-quarter of Singapore residents are expected to have CKD. Many of these patients are not referred to nephrologists. AIM To compare the characteristics of older patients (aged ≥65 years) with CKD stage ≥3B in the referral and non-referral groups. DESIGN & SETTINGS A cross-sectional study in the primary care organisation National University Polyclinics (NUP), Singapore. METHOD Retrospective data were extracted from the electronic health records of patients with CKD (aged ≥65 years) with CKD stage ≥3B. RESULTS From 1 January-31 December 2018, a total of 1536 patients aged ≥65 years were diagnosed with CKD stage ≥3B (non-referral group = 1179 versus referral group = 357). The mean patient age in the non-referral group (78.4 years) was older than that in the referral group (75.9 years) (P<0.001). Indian older patients were referred more compared with their Chinese counterparts (P = 0.008). The non-referral group was prescribed significantly less fibrate, statins, insulin, sulfonylureas, dipeptidyl peptidase-4 (DPP4) inhibitors, and antiplatelet than the referral group (P<0.05), but only the difference in fibrates remained significant on subsequent multivariate analysis. CONCLUSION This study demonstrates that there is a considerable number of older patients with CKD exclusively managed in the primary care setting (n = 1179) and that referrals primarily depend on demographic factors, namely age and ethnic group, rather than medical determinants of CKD severity or case complexity.
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Affiliation(s)
- Wei Beng Tan
- National University Polyclinics, National University Health System, Singapore, Singapore
| | - Anna Szücs
- Division of Family Medicine, Department of Medicine, National University of Singapore, Singapore, Singapore
| | - Sarah M Burkill
- Saw Swee Hock School of Public Health, National University Singapore, Singapore, Singapore
| | - Ong Shih Hui
- Regional Health System Office, National University Health System, Singapore, Singapore
| | - Doris Young
- Division of Family Medicine, Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Goh Lay Hoon
- National University Polyclinics, National University Health System, Singapore, Singapore
- Division of Family Medicine, Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
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Chu L, Bhogal SK, Lin P, Steele A, Fuller M, Ciaccia A, Abitbol A. AWAREness of diagnosis and treatment of Chronic Kidney Disease in adults with Type 2 Diabetes (AWARE-CKD in T2D). Can J Diabetes 2022; 46:464-472. [DOI: 10.1016/j.jcjd.2022.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 01/19/2022] [Accepted: 01/25/2022] [Indexed: 11/27/2022]
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Díez J, Navarro-González JF, Ortiz A, Santamaría R, de Sequera P. Developing the subspecialty of cardio-nephrology: The time has come. A position paper from the coordinating committee from the Working Group for Cardiorenal Medicine of the Spanish Society of Nephrology. Nefrologia 2021; 41:391-402. [PMID: 36165108 DOI: 10.1016/j.nefroe.2021.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 02/21/2021] [Indexed: 06/16/2023] Open
Abstract
Patients with the dual burden of chronic kidney disease (CKD) and cardiovascular disease (CVD) experience unacceptably high rates of morbidity and mortality, which also entail unfavorable effects on healthcare systems. Currently, concerted efforts to identify, prevent and treat CVD in CKD patients are lacking at the institutional level, with emphasis still being placed on individual specialty views on this topic. The authors of this position paper endorse the need for a dedicated interdisciplinary team of subspecialists in cardio-nephrology that manages appropriate clinical interventions across the inpatient and outpatient settings. There is a critical need for training programs, guidelines and best clinical practice models, and research funding from nephrology, cardiology and other professional societies, to support the development of the subspecialty of cardio-nephrology. This position paper from the coordinating committee from the Working Group for Cardiorenal Medicine of the Spanish Society of Nephrology (S.E.N.) is intended to be the starting point to develop the subspecialty of cardio-nephrology within the S.E.N.. The implementation of the subspecialty in day-to-day nephrological practice will help to diagnose, treat, and prevent CVD in CKD patients in a precise, clinically effective, and health cost-favorable manner.
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Affiliation(s)
- Javier Díez
- Departments of Nephrology and Cardiology, University of Navarra Clinic, Pamplona, Spain; Program of Cardiovascular Diseases, Center of Applied Medical Research, University of Navarra, Pamplona, Spain.
| | - Juan F Navarro-González
- Division of Nephrology and Research Unit, University Hospital Nuestra Señora de Candelaria, and Universitary Institute of Biomedical Technologies, University of La Laguna, Santa Cruz de Tenerife, Spain; Red de Investigación Renal (REDINREN), Madrid, Spain
| | - Alberto Ortiz
- Red de Investigación Renal (REDINREN), Madrid, Spain; Division of Nephrology IIS-Fundacion Jimenez Diaz, University Autonoma of Madrid, Madrid, Spain
| | - Rafael Santamaría
- Red de Investigación Renal (REDINREN), Madrid, Spain; Division of Nephrology, University Hospital Reina Sofia, Cordoba, Spain; Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Spain
| | - Patricia de Sequera
- Nephrology Department, Hospital Universitario Infanta Leonor, University Complutense of Madrid, Madrid, Spain
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Crandall CJ, Chen LY, Rodriguez TD, Elashoff D, Faubion SS, Kling JM, Shifren J, Skinner L, Bauer DC. Knowledge and Needs of Resident Physicians Regarding Osteoporosis: A Nationwide Survey of Residents. JBMR Plus 2021; 5:e10524. [PMID: 34368610 PMCID: PMC8328797 DOI: 10.1002/jbm4.10524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/02/2021] [Accepted: 06/15/2021] [Indexed: 11/15/2022] Open
Abstract
Large‐scale studies have not addressed the knowledge level of US resident physicians regarding osteoporosis management. We gauged the knowledge level of family medicine, internal medicine, and obstetrics and gynecology resident physicians regarding osteoporosis management. In 2019, we sent an anonymous survey via e‐mail to all program directors of Accreditation Council for Graduate Medical Education–accredited residency programs in family medicine, internal medicine, and obstetrics and gynecology for distribution to resident physicians. Knowledge items assessed osteoporosis screening, diagnosis, and treatment. We received responses from 182 family medicine, 275 internal medicine, and 122 obstetrics and gynecology programs. Of 582 resident physician respondents, 31% were family medicine residents, 47% were internal medicine residents, and 21% were obstetrics and gynecology residents. Although 77% of respondents correctly selected the T‐score threshold for the diagnosis of osteoporosis among persons aged 50 years and older (−2.5), only 20% of respondents correctly identified minimal‐trauma hip fracture as being diagnostic of osteoporosis. One‐third of respondents correctly identified which medications were demonstrated in clinical trials to decrease hip fracture risk. Fifteen percent of respondents correctly identified that denosumab and alendronate are associated with osteonecrosis of the jaw; and 40% of respondents correctly identified that decline in bone density is more rapid after discontinuation of denosumab than after discontinuation of bisphosphonates. Less than half of resident physicians knew that bisphosphonate‐associated atypical femoral fractures are duration‐dependent. One‐quarter of respondents felt not at all prepared to manage osteoporosis. In this nationwide survey of resident physicians, knowledge regarding osteoporosis diagnosis and treatment was poor, with a striking lack of knowledge regarding the two most serious adverse effects of osteoporosis pharmacotherapy (osteonecrosis of the jaw and atypical femoral fractures). The undertreatment of osteoporosis is unlikely to improve without increased education of resident physicians. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Carolyn J Crandall
- Department of Internal Medicine David Geffen School of Medicine at University of California, Los Angeles Los Angeles CA USA
| | - Lucia Y Chen
- Department of Internal Medicine David Geffen School of Medicine at University of California, Los Angeles Los Angeles CA USA
| | - Tyler D Rodriguez
- Department of Internal Medicine David Geffen School of Medicine at University of California, Los Angeles Los Angeles CA USA
| | - David Elashoff
- Department of Internal Medicine David Geffen School of Medicine at University of California, Los Angeles Los Angeles CA USA
| | | | - Juliana M Kling
- Department of Internal Medicine Mayo Clinic Scottsdale AZ USA
| | - Jan Shifren
- Department of Obstetrics and Gynecology Massachusetts General Hospital, Harvard Medical School Boston MA USA
| | - Lisa Skinner
- Department of Internal Medicine David Geffen School of Medicine at University of California, Los Angeles Los Angeles CA USA
| | - Douglas C Bauer
- Department of Internal Medicine University of California, San Francisco San Francisco CA USA
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10
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Díez J, Navarro-González JF, Ortiz A, Santamaría R, de Sequera P. Developing the subspecialty of cardio-nephrology: The time has come. A position paper from the coordinating committee from the Working Group for Cardiorenal Medicine of the Spanish Society of Nephrology. Nefrologia 2021. [PMID: 33892978 DOI: 10.1016/j.nefro.2021.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Patients with the dual burden of chronic kidney disease (CKD) and cardiovascular disease (CVD) experience unacceptably high rates of morbidity and mortality, which also entail unfavorable effects on healthcare systems. Currently, concerted efforts to identify, prevent and treat CVD in CKD patients are lacking at the institutional level, with emphasis still being placed on individual specialty views on this topic. The authors of this position paper endorse the need for a dedicated interdisciplinary team of subspecialists in cardio-nephrology that manages appropriate clinical interventions across the inpatient and outpatient settings. There is a critical need for training programs, guidelines and best clinical practice models, and research funding from nephrology, cardiology and other professional societies, to support the development of the subspecialty of cardio-nephrology. This position paper from the coordinating committee from the Working Group for Cardiorenal Medicine of the Spanish Society of Nephrology (S.E.N.) is intended to be the starting point to develop the subspecialty of cardio-nephrology within the S.E.N.. The implementation of the subspecialty in day-to-day nephrological practice will help to diagnose, treat, and prevent CVD in CKD patients in a precise, clinically effective, and health cost-favorable manner.
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Affiliation(s)
- Javier Díez
- Departments of Nephrology and Cardiology, University of Navarra Clinic, Pamplona, Spain; Program of Cardiovascular Diseases, Center of Applied Medical Research, University of Navarra, Pamplona, Spain.
| | - Juan F Navarro-González
- Division of Nephrology and Research Unit, University Hospital Nuestra Señora de Candelaria, and Universitary Institute of Biomedical Technologies, University of La Laguna, Santa Cruz de Tenerife, Spain; Red de Investigación Renal (REDINREN), Madrid, Spain
| | - Alberto Ortiz
- Red de Investigación Renal (REDINREN), Madrid, Spain; Division of Nephrology IIS-Fundacion Jimenez Diaz, University Autonoma of Madrid, Madrid, Spain
| | - Rafael Santamaría
- Red de Investigación Renal (REDINREN), Madrid, Spain; Division of Nephrology, University Hospital Reina Sofia, Cordoba, Spain; Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Spain
| | - Patricia de Sequera
- Nephrology Department, Hospital Universitario Infanta Leonor, University Complutense of Madrid, Madrid, Spain
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11
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Snyder MS, Fogel J, Pyatigorskaya S, Rubinstein S. Dose adjustment of antidiabetic medications in chronic kidney disease. Avicenna J Med 2021; 11:33-39. [PMID: 33520787 PMCID: PMC7839266 DOI: 10.4103/ajm.ajm_110_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Purpose: The purpose of this study is to identify whether Internal Medicine house-staff (IMHS) have awareness and knowledge about the correct dosage of antidiabetic medications for patients with chronic kidney disease (CKD), as dosing errors result in adverse patient outcomes for those with diabetes mellitus (DM) and CKD. Methods: There were 353 IMHS surveyed to evaluate incorrect level of awareness of medication dose adjustment in patients with CKD (ILA) and incorrect level of knowledge of glomerular filtration rate level for medication adjustment (ILK-GFR) for Glipizide, Pioglitazone, and Sitagliptin. Results: Lack of awareness and knowledge was high, with the highest for Pioglitazone at 72.8%. For ILA, the percentages were: Pioglitazone: 72.8%, Glipizide: 43.9%, and Sitagliptin: 42.8%. For ILK-GFR, the percentages were: Pioglitazone: 72.8%, Glipizide: 68.3%, and Sitagliptin: 65.4%. Conclusions: IMHS have poor awareness and knowledge for antidiabetic medication dose adjustment in patients with DM and CKD. Both Electronic Medical Rerecord best practice advisory and physician–pharmacist collaborative drug therapy management can enhance safe drug prescribing in patients with CKD. In addition, IMHS’s practice for antidiabetic medication dose adjustment was better with Nephrology exposure. A formal didactic educational training during medical school and residency for antidiabetic medication dose adjustment in patients with DM and CKD is highly encouraged to prevent medication dosing errors and to more effectively and safely allow IMHS to manage complex treatment regimens.
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Affiliation(s)
- Matthew Salvatore Snyder
- New York Institute of Technology College of Osteopathic Medicine, 101 Northern Boulevard, Old Westbury, NY, USA
| | - Joshua Fogel
- Department of Business Management, Brooklyn College, 218 Whitehead Hall, Brooklyn, NY, USA
| | - Svetlana Pyatigorskaya
- Division of Nephrology and Hypertension, Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow, NY, USA
| | - Sofia Rubinstein
- Division of Nephrology and Hypertension, Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow, NY, USA
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Ali SA, Riaz Q, Mushtaq ZM, Awan S, Tariq M. Low performance of internal medicine senior residents in in-service examinations. Postgrad Med J 2021; 98:246-250. [PMID: 33452159 DOI: 10.1136/postgradmedj-2020-138476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 06/14/2020] [Accepted: 12/03/2020] [Indexed: 11/03/2022]
Abstract
We observed an unprecedented and consistent low performance of senior residents as compared with juniors in monthly examinations. This compelled us to evaluate systematically and compare the scores of senior residents with their junior colleagues. This retrospective observational study was conducted in April 2020 among internal medicine residents. Residents in first and second year of their training were labelled as junior residents. Residents in third or fourth year of their training were labelled as senior residents. Comparison of mean scores of each resident level was done separately both for monthly formative multiple-choice questions tests, and summative yearly end of term examinations. We discussed the possible reasons as well. There were 67 residents in year 2018 and 69 in 2019. There is no significant difference between scores of monthly examinations of years 2018 and 2019 among residents of each level. Rather, in March and December 2018, junior residents perform better than senior residents with p values of 0.01 and 0.04, respectively. In February and September 2019, senior residents performed better than junior residents with p value of 0.02. Similarly, there is no significant difference in scores of residents of each level in end-of-term examinations of years 2018 and 2019 with p values 0.18 and 0.25, respectively. Performance of senior residents in our residency programme in in-service examinations is relatively low as compared with their junior colleagues. There is a need to evaluate reasons for this relatively low performance of senior residents.
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Affiliation(s)
| | - Qamar Riaz
- Department of Educational Development, Faculty of Health Sciences, The Aga Khan University, Karachi, Pakistan
| | | | - Safia Awan
- Medicine, Aga Khan University, Karachi, Sind, Pakistan
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Adeniyi OV, Owolabi EO. Cross-sectional study of diabetes kidney disease in the Eastern Cape, South Africa. Medicine (Baltimore) 2020; 99:e23303. [PMID: 33327258 PMCID: PMC7738037 DOI: 10.1097/md.0000000000023303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 10/16/2020] [Accepted: 10/22/2020] [Indexed: 12/17/2022] Open
Abstract
Diabetes mellitus (DM) is an independent risk factor for the development of kidney disease. This study assesses the prevalence and determinants of asymptomatic kidney disease in individuals with DM attending health facilities in OR Tambo district, Eastern Cape, South Africa.In this cross-sectional analysis, medical data of 327 individuals receiving care for DM in primary health care centers in OR Tambo district, Eastern Cape between June and November 2013 were reviewed. Significant kidney disease was defined as estimated glomerular filtration rate less than 60 mL/min/1.73 m in accordance with the guidelines of the Society of Endocrinology, Metabolism and Diabetes of South Africa (2017).One-quarter of the 327 participants (n = 80) had significant kidney disease. Female sex [odds ratio (OR) = 5.2; 95% confidence interval (95% CI) 1.2-23.5], never used alcohol (OR = 13.4; 95% CI 2.5-72.1), hypertension (OR = 16.2; 95% CI 2.0-130.0), triglyceride (TG)/high-density lipoprotein (HDL) ratio (OR = 1.2; 95% CI 1.0-1.5), current smoker (OR = 1127.9; 95% CI 162.9-7808.9), former smoker (OR = 13.3; 95% CI 4.1-41.4), and longer duration of diabetes (OR = 4.6; 95% CI 1.6-13.0) were the independent determinants of significant kidney disease among the participants. A significant dose--effect relationship exists between renal disease and smoking status (P < .0001), duration of DM (P < .001), glycemic status (P = .025), and body mass index (P = .003).There is a high rate of undiagnosed kidney disease in this setting, which was independently associated with female sex and presence of other cardiovascular risk factors. Strategic interventions targeting screening and monitoring of renal functions in individuals with DM are urgently needed in this region.
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Affiliation(s)
- Oladele Vincent Adeniyi
- Department of Family Medicine, Faculty of Health Sciences, Walter Sisulu University/Cecilia Makiwane Hospital, East London
| | - Eyitayo Omolara Owolabi
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Pickup L, Law JP, Townend JN, Ferro CJ. Cardiorenal medicine: an emerging new speciality or a need for closer collaboration? THE BRITISH JOURNAL OF CARDIOLOGY 2020; 27:25. [PMID: 35747771 PMCID: PMC9205234 DOI: 10.5837/bjc.2020.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Luke Pickup
- British Heart Foundation Clinical Research Training Fellow and Specialist Registrar in Cardiology, Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT
| | - Jonathan P Law
- British Heart Foundation Clinical Research Training Fellow and Specialist Registrar in Nephrology Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT
| | - Jonathan N Townend
- Consultant Cardiologist and Professor of Cardiology, Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT
| | - Charles J Ferro
- Consultant Nephrologist and Professor of Nephrology, Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT
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15
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Screening for chronic kidney disease in a hypertensive primary care cohort. J Am Assoc Nurse Pract 2020; 33:630-638. [PMID: 34397752 DOI: 10.1097/jxx.0000000000000434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 03/11/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Screening rates for chronic kidney disease (CKD) in primary care settings remain low. Although primary care providers are well positioned to offer this testing, there are many barriers that contribute to low screening rates. PURPOSE The purpose of this study was to examine both practice and contextual factors that relate to screening for CKD in a cohort of primary care patients with hypertension. METHODS A mixed-methods, single-embedded, convergent parallel design was used for this organizational case study. The Chronic Care Model served as the framework. Electronic medical record data, resource walk-through, and provider surveys were collected from selected primary care clinics within one large academic medical center in the Pacific Northwest. Analyses included regression models, descriptive statistics, narrative content analysis, and pattern matching for organizational case creation. RESULTS Screening rates were low in the cohort, but patients with more risk factors for CKD were more likely to receive orders for screening. Organizational and community support was deemed necessary for primary care providers to effectively translate guidelines into practice. IMPLICATIONS FOR PRACTICE The results of this study offer support for a wholistic approach to guideline translation into practice. Participants in the study were open to increased screening for CKD but needed support in multiple ways from the organization. Guidelines alone were not deemed the ideal vehicles for translation of research into practice.
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Physicians' Recognition and Management of Kidney Disease: A Randomized Vignette Study Evaluating the Impact of the KDIGO 2012 CKD Classification System. Kidney Med 2020; 2:258-266. [PMID: 32734245 PMCID: PMC7380357 DOI: 10.1016/j.xkme.2019.12.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Rationale & Objective The Kidney Disease Outcome Quality Initiative (KDOQI) and Kidney Disease: Improving Global Outcomes (KDIGO) chronic kidney disease (CKD) classification systems published in 2002 and 2012, respectively, are recommended worldwide and based on strong epidemiologic data. However, their impact on CKD recognition and management is not well evaluated in clinical practice, and we therefore investigated whether they help physicians recognize and appropriately care for patients with CKD. Study Design Randomized vignette experiment with fractional factorial design based on 6 kidney-related scenarios and 3 laboratory presentation methods reflecting the CKD guidelines. Participants evaluated 1 of 3 subsets of the 18 vignettes (ie, 6 vignettes each with 4 answer alternatives). Setting & Participants 249 interns, general practitioners, and residents/fellows attending postgraduate meetings and courses in Norway and the United States. Intervention Kidney-related results (serum creatinine level and urinary albumin excretion) were presented as the “minimal data” (high/low levels), KDOQI-2002 (estimated glomerular filtration rate [eGFR] reported automatically), or KDIGO-2012 (eGFR + albuminuria categorization + risk for complications) laboratory report. Outcome CKD management choice by physicians. Results When kidney laboratory data were presented as the KDOQI-2002 report (automatic eGFR calculation), there was a significantly higher odds for correct patient management decisions compared with the minimal data report (OR, 1.57; P < 0.001). Additional significant improvement was obtained with the KDIGO-2012 report (OR, 2.28 for correct answer vs minimal data report [P < 0.001]; OR, 1.45 compared to KDOQI-2002 report [P = 0.005]). The KDIGO classification system improved physician management in 4 of the 6 clinical scenarios covering a wide range of kidney-related topics. Interaction analysis showed that general practitioners and those with 1 to 3 years of internal medicine experience had the greatest improvements with the new presentation techniques. Limitations Physicians’ management was evaluated by theoretical scenarios rather than direct patient care. Conclusions Automatic GFR estimation, albuminuria categorization, and notification of the associated risk for complications improve most physicians` recognition and management of a wide range of CKD clinical scenarios.
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Sperati CJ, Soman S, Agrawal V, Liu Y, Abdel-Kader K, Diamantidis CJ, Estrella MM, Cavanaugh K, Plantinga L, Schell J, Simon J, Vassalotti JA, Choi MJ, Jaar BG, Greer RC. Primary care physicians' perceptions of barriers and facilitators to management of chronic kidney disease: A mixed methods study. PLoS One 2019; 14:e0221325. [PMID: 31437198 PMCID: PMC6705804 DOI: 10.1371/journal.pone.0221325] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 08/06/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Given the high prevalence of chronic kidney disease (CKD), primary care physicians (PCPs) frequently manage early stage CKD. Nonetheless, there are challenges in providing optimal CKD care in the primary care setting. This study sought to understand PCPs' perceptions of barriers and facilitators to the optimal management of CKD. STUDY DESIGN Mixed methods study. SETTINGS AND PARTICIPANTS Community-based PCPs in four US cities: Baltimore, MD; St. Louis, MO; Raleigh, NC and San Francisco, CA. METHODOLOGY We used a self-administered questionnaire and conducted 4 focus groups of PCPs (n = 8 PCPs/focus group) in each city to identify key barriers and facilitators to management of patients with CKD in primary care. ANALYTIC APPROACH We conducted descriptive analyses of the survey data. Major themes were identified from audio-recorded interviews that were transcribed and coded by the research team. RESULTS Of 32 participating PCPs, 31 (97%) had been in practice for >10 years, and 29 (91%) practiced in a non-academic setting. PCPs identified multiple barriers to managing CKD in primary care including at the level of the patient (e.g., low awareness of CKD, poor adherence to treatment recommendations), the provider (e.g., staying current with CKD guidelines), and the health care system (e.g., inflexible electronic medical record, limited time and resources). PCPs desired electronic prompts and lab decision support, concise guidelines, and healthcare financing reform to improve CKD care. CONCLUSIONS PCPs face substantial but modifiable barriers in providing care to patients with CKD. Interventions that address these barriers and promote facilitative tools may improve PCPs' effectiveness and capacity to care for patients with CKD.
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Affiliation(s)
- C. John Sperati
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Sandeep Soman
- Division of Nephrology, Henry Ford Hospital, Detroit, Michigan, United States of America
| | - Varun Agrawal
- Division of Nephrology and Hypertension, University of Vermont College of Medicine, Burlington, Vermont, United States of America
| | - Yang Liu
- Johns Hopkins Medicine International, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States of America
| | - Khaled Abdel-Kader
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center; Vanderbilt Center for Kidney Disease, Nashville, Tennessee, United States of America
| | - Clarissa J. Diamantidis
- Divisions of General Internal Medicine and Nephrology, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Michelle M. Estrella
- Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco and San Francisco VA Health Care System, San Francisco, California, United States of America
| | - Kerri Cavanaugh
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center; Vanderbilt Center for Kidney Disease, Nashville, Tennessee, United States of America
| | - Laura Plantinga
- Department of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - Jane Schell
- Section of Palliative Care and Medical Ethics, Division of Renal-Electrolyte, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States of America
| | - James Simon
- Department of Nephrology and Hypertension, Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Joseph A. Vassalotti
- Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
- National Kidney Foundation, New York, New York, United States of America
| | - Michael J. Choi
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Bernard G. Jaar
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Nephrology Center of Maryland, Baltimore, Maryland, United States of America
- The Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, Maryland, United States of America
| | - Raquel C. Greer
- The Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, Maryland, United States of America
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
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Saad CY, Fogel J, Rubinstein S. Awareness and Knowledge Among Internal Medicine Resident Trainees for Dose Adjustment of Analgesics and Neuropsychotropic Medications in CKD. South Med J 2018; 111:155-162. [PMID: 29505650 DOI: 10.14423/smj.0000000000000781] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Errors in drug dosing lead to poor patient outcomes and are common in patients with chronic kidney disease (CKD). Because the majority of patients with CKD are being treated by physicians specializing in internal medicine, we studied the awareness and knowledge that internal medicine resident trainees (IMRTs) have regarding the correct dosage of commonly used analgesic and neuropsychotropic medications for patients with CKD. METHODS We surveyed 353 IMRTs about their awareness of whether a medication needs dose adjustment in patients with CKD and knowledge for medication adjustment by level of glomerular filtration rate. RESULTS There were high percentages for lack of awareness and knowledge. For analgesics, this lack of awareness/knowledge was highest for acetaminophen (awareness 83.0%, knowledge 90.9%). For neuropsychotropics, this was highest for paroxetine (awareness 74.5%, knowledge 91.5%). Analyses for postgraduate year (PGY) -1 trainees and PGY-2 trainees for analgesics showed higher odds for lack of awareness for tramadol (PGY-1 odds ratio [OR] 2.37, 95% confidence interval [CI] 1.2-4.62, P < 0.05; PGY-2 OR 2.34, 95% CI 1.16-4.72, P < 0.05) and for lack of knowledge for meperedine (PGY-1 OR 4.01, 95% CI 1.81-8.89, P < 0.05; PGY-2 OR 3.30, 95% CI 1.44-7.59, P < 0.05). Nephrology residency rotation for the neuropsychotropic medication of gabapentin showed lower odds for both lack of awareness (OR 0.56, 95% CI 0.32-0.97, P < 0.05) and knowledge (OR 0.52, 95% CI 0.27-0.997, P < 0.05). CONCLUSIONS Awareness and knowledge are poor among IMRTs for dose adjustments of analgesics and neuropsychotropic medication classes in patients with CKD. There should be a renewed focus during IMRTs' residency on additional nephrology exposure and formal didactic educational training to help them better manage complex treatment regimens to prevent medication dosing errors.
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Affiliation(s)
- Chadi Y Saad
- From the Division of Nephrology and Hypertension, Nassau University Medical Center, East Meadow, New York, and the Department of Business Management, Brooklyn College, Brooklyn, New York
| | - Joshua Fogel
- From the Division of Nephrology and Hypertension, Nassau University Medical Center, East Meadow, New York, and the Department of Business Management, Brooklyn College, Brooklyn, New York
| | - Sofia Rubinstein
- From the Division of Nephrology and Hypertension, Nassau University Medical Center, East Meadow, New York, and the Department of Business Management, Brooklyn College, Brooklyn, New York
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De Wilde M, Speeckaert M, Van Biesen W. Can increased vigilance for chronic kidney disease in hospitalised patients decrease late referral and improve dialysis-free survival? BMC Nephrol 2018; 19:74. [PMID: 29606094 PMCID: PMC5880091 DOI: 10.1186/s12882-018-0869-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 03/12/2018] [Indexed: 11/26/2022] Open
Abstract
Background Insufficient vigilance for renal insufficiency is associated with late referral, increased morbidity and mortality. The present study examines whether increased vigilance for chronic kidney disease (CKD) leads to quicker referral to and better follow-up by a nephrologist, and whether it is associated with an improved outcome. Methods Patients with an eGFR < 45 ml/min/1.73 m2 during hospitalisation at the Ghent University Hospital were enrolled during a period of 100 days. The patients were interviewed about their awareness of CKD. Both the patients and their general practitioner were subsequently informed about CKD. The primary endpoint was the number of patients referred for nephrological follow-up within three months. The secondary endpoint was need for dialysis and mortality from any cause one year after inclusion. Results Of the 72 included patients, 54 had proven CKD, with eGFR consistently < 45 ml/min/1.73 m2 during at least three months before inclusion. Merely 65% was aware of having CKD and only 41% was in regular nephrological follow-up. After intervention, the percentage of patients with CKD in follow-up increased from 41% to 71% (p = 0.002). The proportion reaching the secondary endpoint was significant lower in the patients who were referred quickly than in those who were not (p = 0.015). Similarly, the proportion was significant lower in the patients who received nephrological follow-up than in those who did not (p = 0.006). Conclusion Vigilance for CKD is poor. Simple interventions to augment the vigilance for CKD, as presented in this study, lead to a quicker referral to and follow-up by a nephrologist, which may result in better outcome.
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Affiliation(s)
- M De Wilde
- Department of Nephrology, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium.
| | - M Speeckaert
- Department of Nephrology, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium
| | - W Van Biesen
- Department of Nephrology, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium
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Garg G, Wright Nunes J. Commentary on “Awareness and Knowledge Among Internal Medicine Resident Trainees for Dose Adjustment of Analgesics and Neuropsychotropic Medications in CKD”. South Med J 2018; 111:163-164. [DOI: 10.14423/smj.0000000000000782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Ronco C, Ronco F, McCullough PA. A Call to Action to Develop Integrated Curricula in Cardiorenal Medicine. Blood Purif 2017; 44:251-259. [PMID: 29065398 DOI: 10.1159/000480318] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
With the adoption of the new definition and classification of cardiorenal syndrome (CRS) and its relevant subtypes, much attention has been placed on elucidating the mechanisms of heart and kidney interactions. Of great interest are the pathophysiological pathways by which acute heart failure may result in acute kidney injury (AKI; type 1), chronic heart failure accelerating the progression of chronic kidney disease (CKD; type 2), AKI provoking cardiac events (type 3), and CKD increasing the risk and severity of cardiovascular disease (type 4). A remarkable interest has also been placed on the acute and chronic systemic conditions, such as sepsis and diabetes, which simultaneously affect heart and kidney function (type 5). Furthermore, the physiology of acute and chronic heart-kidney cross talk is drawing attention to hemodynamics (fluids, pressures, flows, resistances, perfusion), physiochemical (electrolytes, pH, and toxins), and biological (inflammation, immune system activation, neurohormonal signals) processes. Common clinical scenarios call for recognition, knowledge, and skill in managing CRS. There is a clear need for medical and surgical specialists that are well versed in the pathophysiology and the clinical manifestations that arise in the setting of CRS. With this editorial, we are making a call to action to stimulate universities, medical schools, and teaching hospitals to create a core curriculum for cardiorenal medicine to better equip the physicians of the future for these common, serious, and frequently fatal syndromes.
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Affiliation(s)
- Claudio Ronco
- Department of Nephrology, San Bortolo Hospital, Vicenza, Italy
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Trevethan R. Deconstructing and Assessing Knowledge and Awareness in Public Health Research. Front Public Health 2017; 5:194. [PMID: 28824900 PMCID: PMC5545880 DOI: 10.3389/fpubh.2017.00194] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 07/19/2017] [Indexed: 12/15/2022] Open
Abstract
When people's knowledge and awareness are the subject of public health research, the meanings applied to the words knowledge and awareness are often unclear. Although frequently used interchangeably without that being problematic, these words sometimes appear to have different intended meanings but those meanings are not made explicit or, despite the meanings having been made explicit, they are not adhered to. It is necessary to overcome obscurities when knowledge and awareness are intended to represent different domains. This occurs when they are compared with each other; it also occurs when knowledge and awareness are assessed separately in relation to such variables as health behavior; physical, psychological, or socioeconomic statuses; gender; age; and ethnic backgrounds. For those particular research ventures, recommendations are made that knowledge be used to refer to information that is, to a greater or lesser extent, detailed and factual, and that awareness be associated with information that is personally relevant. Some suggestions are made, and issues are raised, about how the psychometric foundations for each of those two domains might be established prior to use in empirical research. Adopting the recommendations and suggestions made in this article provides opportunities for greater conceptual and empirical clarity and success.
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Affiliation(s)
- Robert Trevethan
- Independent academic researcher and author, Albury, NSW, Australia
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Singh K, Waikar SS, Samal L. Evaluating the feasibility of the KDIGO CKD referral recommendations. BMC Nephrol 2017; 18:223. [PMID: 28687072 PMCID: PMC5501411 DOI: 10.1186/s12882-017-0646-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 06/28/2017] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND In 2012, the international nephrology organization Kidney Disease Improving Global Outcomes (KDIGO) released recommendations for nephrology referral for chronic kidney disease (CKD) patients. The feasibility of adhering to these recommendations is unknown. METHODS We conducted a retrospective analysis of the primary care population at Brigham and Women's Hospital (BWH). We translated referral recommendations based upon serum creatinine, estimated glomerular filtration rate (eGFR), and albuminuria into a set of computable criteria in order to project referral volume if the KDIGO referral recommendations were to be implemented. Using electronic health record data, we evaluated each patient using the computable criteria at the times that the patient made clinic visits in 2013. We then compared the projected referral volume with baseline nephrology clinic volume. RESULTS Out of 56,461 primary care patients at BWH, we identified 5593 (9.9%) who had CKD based on albuminuria or estimated GFR. Referring patients identified by the computable criteria would have resulted in 2240 additional referrals to nephrology. In 2013, this would represent a 38.0% (2240/5892) increase in total nephrology patient volume and 67.3% (2240/3326) increase in new referral volume. CONCLUSIONS This is the first study to examine the projected impact of implementing the 2012 KDIGO referral recommendations. Given the large increase in the number of referrals, this study is suggestive that implementing the KDIGO referral guidelines may not be feasible under current practice models due to a supply-demand mismatch. We need to consider new strategies on how to deliver optimal care to CKD patients using the available workforce in the U.S. health care system.
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Affiliation(s)
- Karandeep Singh
- Division of Learning and Knowledge Systems, Department of Learning Health Sciences, University of Michigan Medical School, 1161H NIB, 300 N. Ingalls St, Ann Arbor, MI, 48109-5403, USA. .,Division of Nephrology, Department of Internal Medicine, University of Michigan Medical School, 1161H NIB, 300 N. Ingalls St, Ann Arbor, MI, 48109-5403, USA.
| | - Sushrut S Waikar
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis St, MRB4, Boston, MA, 02115, USA.,Harvard Medical School, Boston, MA, USA
| | - Lipika Samal
- Division of General Medicine, Brigham and Women's Hospital, 1620 Tremont St Suite 03-02V, Boston, MA, 02120, USA.,Harvard Medical School, Boston, MA, USA
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Obadan NO, Walker RJ, Egede LE. Independent correlates of chronic kidney disease awareness among adults with type 2 diabetes. J Diabetes Complications 2017; 31:988-991. [PMID: 28363729 PMCID: PMC5438883 DOI: 10.1016/j.jdiacomp.2017.03.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 03/02/2017] [Accepted: 03/14/2017] [Indexed: 01/06/2023]
Abstract
BACKGROUND Chronic Kidney Disease (CKD) is usually silent until advanced stages. Awareness of CKD is important to mitigate poorer outcomes. This study aims to understand the relationship(s) between CKD self-awareness and diagnosed CKD. METHODS The study included 345 adults with type 2 diabetes from two primary care settings. Participants completed surveys assessing demographic information, self-care behaviors and co-morbidities. Biological data were taken from medical records. CKD was diagnosed as eGFR=<59ml/min. CKD awareness was defined by a positive response to "has a doctor, nurse or other health professional ever told you that you have a kidney disease?" and/or "have you ever had kidney failure that required dialysis or a kidney transplant?" Logistic regression models were used to examine the association between CKD awareness and clinical/socio-demographic variables. RESULTS 31% of study patients had CKD based on eGFR (of which only 63% were aware). Stepwise regression showed that non-Hispanic blacks (OR=3.49, p=0.04), those with college education (OR=8.02, p=0.01), history of myocardial infarction (OR=10.12, p=0.002) or hypertension (OR=23.25, p=0.02), and those with Medicare, VA insurance, or other insurance (OR=8.08, 8.72, 101.47, respectively, p<0.01) were significantly more likely to be aware of CKD. Those with a history of stroke or depression (OR=0.21, 0.28, respectively, p=0.03, p=0.04) were significantly less likely to be aware of CKD. CONCLUSION CKD awareness was found to be lower than diagnosed CKD rates. Factors associated with awareness include race, educational status and cardiovascular disease. Targeted strategies to increase CKD awareness may lead to improved health outcomes.
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Affiliation(s)
- Ndidiamaka O Obadan
- Department of Medicine, Division of Nephrology, Medical University of South Carolina, Charleston, SC
| | - Rebekah J Walker
- Department of Medicine, Division of General Internal Medicine, Froedtert and The Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI, USA 53226; Center for Patient Care and Outcomes Research, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, USA 53226
| | - Leonard E Egede
- Department of Medicine, Division of General Internal Medicine, Froedtert and The Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI, USA 53226; Center for Patient Care and Outcomes Research, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, USA 53226.
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Evans R, Rudd P, Hemmila U, Dobbie H, Dreyer G. Deficiencies in education and experience in the management of acute kidney injury among Malawian healthcare workers. Malawi Med J 2016; 27:101-3. [PMID: 26715955 DOI: 10.4314/mmj.v27i3.6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a common but under-recognised disease process, which carries a high risk of mortality or chronic complications, such as chronic kidney disease and other organ dysfunction. Management of AKI, however, is suboptimal, both in developed settings and in Malawi. This is partly because of deficiencies in AKI education and training. AIM To establish current levels of AKI education in a range of healthcare workers in Malawi. METHODS An AKI symposium was held in Blantyre in March 2015. Delegates were asked to complete a survey at the start of the symposium to assess their clinical experience and education in the management of AKI. RESULTS From 100 delegates, 89 nurses, clinical officers, and physicians, originating from 11 different districts, responded to the survey. Twenty-two percent of healthcare workers (including 28% of district workers of the various cadres and 31% of nurses) had never received teaching on any aspect of renal disease, and 50% (including 63% of district workers and 61% of nurses) had never received teaching specifically on AKI. Forty-four percent did not feel confident managing AKI, and 98% wanted more support managing patients with renal disease. Thirty-four percent (including 55% of district workers) were unaware that haemodialysis was available at Queen Elizabeth Central Hospital (QECH) for the treatment of AKI and 53% (74% of district workers) were unaware that peritoneal dialysis was available for the treatment of AKI in children. Only 33% had ever referred a patient with AKI to QECH. CONCLUSIONS There are deficiencies in education about, and clinical experience in, the management of AKI among Malawian healthcare workers, in addition to limited awareness of the renal service available at QECH. Urgent action is required to address these issues in order to prevent morbidity and mortality from AKI in Malawi.
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Affiliation(s)
- R Evans
- Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi ; Department of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - P Rudd
- Department of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - U Hemmila
- Department of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - H Dobbie
- Nephrology Department, Bart's Health, London, United Kingdom
| | - G Dreyer
- Department of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi ; Nephrology Department, Bart's Health, London, United Kingdom
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Buttigieg J, Mercieca L, Saliba A, Aquilina S, Farrugia E, Fava S. Chronic kidney disease referral practices among non-nephrology specialists: A single-centre experience. Eur J Intern Med 2016; 29:93-7. [PMID: 26809863 DOI: 10.1016/j.ejim.2016.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 12/22/2015] [Accepted: 01/10/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Early referral of CKD patients to nephrology teams (NT) is vital to identify patients most likely to progress, delay decline of excretory function, and provide planned RRT. Unfortunately, many are still being referred late. METHODS We conducted a retrospective analysis to investigate referral rates, predictors of non-referral, and performed urine investigations in hospitalised CKD patients. RESULTS Out of 388 patients studied, 5.6%, 11.4%, and 16.4% in CKD3A, 3B, and 4+5, respectively, were referred to an NT upon discharge (CKD3A vs. CKD4+5, p=0.016). For every additional year of age, the odds of being referred decreased by 5% (OR: 0.95, CI: 0.92-0.98, p=0.003). Patients were more likely to be referred to an NT if they were males (OR: 2.31, CI: 1.09-4.90, p=0.029) and having reached CKD 4+5 (OR: 3.99, CI: 1.58-10.10, p=0.003). Only 28.8%, 43.9%, and 50.7% of patients with CKD3A, 3B, and 4+5 were followed up with urine investigations after discharge (p=0.001). CKD stage 3B (OR: 3.54, CI: 1.23-10.19, p=0.019), CKD stage 4+5 (OR: 6.06, CI: 1.69-21.67, p=0.006), DM (OR: 6.28, CI: 2.38-16.58, p<0.0001), and having been referred to a NT (OR: 20.95, CI: 3.54-123.92, p=0.001) were independent predictors for having urine investigations. CONCLUSION The highest rate of referral was achieved in males, younger age group, and those who have reached CKD stage 4+5. Urine tests remain largely underutilised and only a minority (16.4%) of patients with an eGFR <30mL/min/1.73m(2) were referred to a NT.
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Affiliation(s)
| | - Liam Mercieca
- Department of Medicine, Mater Dei Hospital, Msida, Malta.
| | - Arielle Saliba
- Department of Medicine, Mater Dei Hospital, Msida, Malta.
| | - Simon Aquilina
- Department of Medicine, Mater Dei Hospital, Msida, Malta.
| | | | - Stephen Fava
- Diabetes and Endocrine Department, Mater Dei Hospital, Msida, Malta.
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Magalhães FG, Goulart RMM. Doença renal crônica e tratamento em idosos: uma revisão integrativa. REVISTA BRASILEIRA DE GERIATRIA E GERONTOLOGIA 2015. [DOI: 10.1590/1809-9823.2015.14132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
ResumoO envelhecimento populacional, juntamente com a crescente incidência de doenças crônicas, tem contribuído para o aumento mundial da prevalência da doença renal crônica (DRC). O objetivo deste estudo foi realizar uma revisão integrativa sobre os tratamentos propostos para idosos portadores de DRC na fase não dialítica. Foi efetuada uma busca na literatura, considerando-se o período entre janeiro de 2002 e maio de 2013, nas bases de dados eletrônicas MEDLINE, LILACS, SciELO e Science Direct, a partir das palavras-chave: chronic kidney disease, treatment e elderly. Foram incluídos os artigos livremente disponíveis e completos. Inicialmente, foram identificados 215 artigos. Após a etapa de elegibilidade, 13 artigos foram incluídos nessa revisão integrativa. As intervenções terapêuticas recomendadas para a gestão da DRC incluem o controle de hipertensão arterial, diabetes e dislipidemia, alterações alimentares, redução de peso e abstinência do fumo. Em relação ao tratamento, para muitos idosos com DRC, uma abordagem individualizada centrada no paciente pode ter mais a oferecer do que a abordagem tradicional orientada na doença. Quanto ao encaminhamento precoce ao nefrologista, esse parece ser um procedimento que apresenta benefícios na gestão da doença renal. Embora haja um esforço aparente dos pesquisadores em instituir abordagens terapêuticas mais adequadas, ainda são escassas as evidências de intervenções que melhorem a sobrevida de pacientes idosos com DRC. Contudo, algumas intervenções evitam agudizações e retardam a evolução da DRC. Nesse sentido, há necessidade da realização de estudos randomizados controlados de longo prazo incluindo indivíduos idosos com DRC, a fim de se conhecer procedimentos terapêuticos mais eficazes para o controle dessa doença.
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Underprescription of Renin–Angiotensin System Blockers in Moderate to Severe Chronic Kidney Disease. Am J Med Sci 2015; 349:510-5. [DOI: 10.1097/maj.0000000000000475] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Perotte A, Ranganath R, Hirsch JS, Blei D, Elhadad N. Risk prediction for chronic kidney disease progression using heterogeneous electronic health record data and time series analysis. J Am Med Inform Assoc 2015; 22:872-80. [PMID: 25896647 PMCID: PMC4482276 DOI: 10.1093/jamia/ocv024] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 03/08/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND As adoption of electronic health records continues to increase, there is an opportunity to incorporate clinical documentation as well as laboratory values and demographics into risk prediction modeling. OBJECTIVE The authors develop a risk prediction model for chronic kidney disease (CKD) progression from stage III to stage IV that includes longitudinal data and features drawn from clinical documentation. METHODS The study cohort consisted of 2908 primary-care clinic patients who had at least three visits prior to January 1, 2013 and developed CKD stage III during their documented history. Development and validation cohorts were randomly selected from this cohort and the study datasets included longitudinal inpatient and outpatient data from these populations. Time series analysis (Kalman filter) and survival analysis (Cox proportional hazards) were combined to produce a range of risk models. These models were evaluated using concordance, a discriminatory statistic. RESULTS A risk model incorporating longitudinal data on clinical documentation and laboratory test results (concordance 0.849) predicts progression from state III CKD to stage IV CKD more accurately when compared to a similar model without laboratory test results (concordance 0.733, P<.001), a model that only considers the most recent laboratory test results (concordance 0.819, P < .031) and a model based on estimated glomerular filtration rate (concordance 0.779, P < .001). CONCLUSIONS A risk prediction model that takes longitudinal laboratory test results and clinical documentation into consideration can predict CKD progression from stage III to stage IV more accurately than three models that do not take all of these variables into consideration.
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Affiliation(s)
- Adler Perotte
- Biomedical Informatics Department, Columbia University, New York, NY, USA
| | - Rajesh Ranganath
- Computer Science Department, Princeton University, Princeton, NJ, USA
| | - Jamie S Hirsch
- Biomedical Informatics Department, Columbia University, New York, NY, USA Division of Nephrology, Columbia University, New York, NY, USA
| | - David Blei
- Statistics Department, Columbia University, New York, NY, USA
| | - Noémie Elhadad
- Biomedical Informatics Department, Columbia University, New York, NY, USA
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de Miguel-Yanes JM, Inglada-Galiana L, Gómez-Huelgas R. Prioritization of patient-related factors according to renal function in antidiabetic drug selection: the REDIM Project. Diabetes Res Clin Pract 2014; 105:199-205. [PMID: 24890859 DOI: 10.1016/j.diabres.2014.04.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 04/25/2014] [Accepted: 04/27/2014] [Indexed: 01/15/2023]
Abstract
AIMS Few studies have evaluated how physicians prioritize renal function among other patient-related factors when stepping-up in antidiabetic treatment. METHODS The REDIM Spanish national online survey included 550 internists. We firstly tested proficiency in chronic kidney disease (Agrawal's Questionnaire) and motivation in diabetes (DAS-3p Questionnaire). We then analyzed how physicians prioritized renal function, age, weight, glycemic control, non-renal co-morbidities and patient perceptions in five varying fictitious clinical scenarios (generic; ambulatory vs. high cardiovascular risk hospitalized patient, for estimated glomerular filtration rates (eGFRs)=50 vs. 25 ml/min/1.73 m(2)). We assigned every item a score (from 5 to 0, highest to lowest relevance) per-physician and compared mean values between clinical scenarios using the t-test for independent means (nominal significance at p<0.05). RESULTS Completion rate was 57.5% (N=316; mean age, 46.3 years; men, 71%). Average scores were 22.6 ± 3.9 (possible range [0-30]) for Agrawal's Questionnaire and 4.1 ± 0.6 (range [1-5]) for DAS-3p Questionnaire. In the generic scenario, renal function had the highest priority (mean=3.36 ± 1.66, range [0-5]). When eGFR was set at 50 ml/min/1.73 m(2), physicians prioritized glycemic control for ambulatory (mean=3.23 ± 1.59) and non-renal co-morbidities for hospitalized patients (mean=3.20 ± 1.68) over renal function (mean=3.18 ± 1.77 for ambulatory, p=0.032; mean=3.11 ± 1.65 for hospitalized patients, p=0.002). When eGFR was subsequently lowered to 25 ml/min/1.73 m(2), renal function again led priorities (mean values=3.73 ± 2.05 for ambulatory and 3.75 ± 1.96 for hospitalized patients; both p<0.001). CONCLUSIONS Knowledge of the degree of renal function impairment induced physicians to prioritize patient-related factors differently when adding a second antidiabetic drug. Renal function led priorities when severely impaired.
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Troidle L. The chronic kidney disease patient in the acute hospital environment. Adv Chronic Kidney Dis 2014; 21:355-9. [PMID: 24969387 DOI: 10.1053/j.ackd.2014.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 05/21/2014] [Accepted: 05/21/2014] [Indexed: 11/11/2022]
Abstract
CKD is common, affecting more than 10% of the adult US population. Hospital admissions are common among these patients and present challenges for their caregivers. In the acute hospital setting, there is often a lack of awareness of the CKD patient and the best practices developed to help this population. This can place the CKD patient at risk for medication errors such as incorrect dosage or administration of a potentially harmful or unhelpful medication. CKD patients may need procedures during a hospital stay that increase their risk of adverse events. Also, common admission practices such as placing intravenous access needs to be thoughtfully considered in this population.
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Abdel-Kader K, Greer RC, Boulware LE, Unruh ML. Primary care physicians' familiarity, beliefs, and perceived barriers to practice guidelines in non-diabetic CKD: a survey study. BMC Nephrol 2014; 15:64. [PMID: 24755164 PMCID: PMC4021215 DOI: 10.1186/1471-2369-15-64] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 04/16/2014] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Most non-dialysis dependent chronic kidney disease (CKD) patients are cared for by their primary care physicians (PCPs). Studies suggest many CKD patients receive suboptimal care. Recently, CKD clinical practice guidelines were updated with additional emphasis on albuminuria. METHODS We performed an internet-based, cross-sectional survey of active PCPs in the United States using the American Medical Association Physician Masterfile. We explored CKD guideline familiarity, self-reported practice behaviors, and attitudinal and external barriers to implementing guideline recommendations, including albuminuria testing. RESULTS Of 12,034 PCPs targeted, 848 opened a study email, 165 (19.5%) responded. Most respondents (88%) spent ≥50% of their time in clinical care. Respondents were generally in private practice (46%). Most PCPs (96%) felt that eGFR values were helpful. Approximately, 75% and 91% of PCPs reported testing for albuminuria in non-diabetic hypertensive patients with an eGFR > 60 ml/min/1.73 m2 and < 60 ml/min/1.73 m2, respectively. Barriers to albuminuria testing included a lack of effect on management, limited time, and the perceived absence of guidelines recommending testing. While PCPs expressed high levels of agreement with the definition of CKD, 30% were concerned with overdiagnosis in older adults with an eGFR in the CKD stage 3a range. Most PCPs felt that angiotensin converting enzyme inhibitor (ACEi)/ angiotensin II receptor blockers (ARBs) improved outcomes in CKD, though agreement was lower with severe vs. moderate albuminuria (78% vs. 85%, respectively, p = 0.03). Many PCPs (51%) reported being unfamiliar with CKD guidelines, but were receptive to systematic interventions to improve their CKD care. CONCLUSIONS PCPs generally agree with CKD clinical practice guidelines regarding CKD definition and albuminuria testing. However, future interventions are necessary to improve PCPs' familiarity with CKD guidelines, overcome barriers to albuminuria testing and, assist PCPs in targeting ACEi/ARBs to the patients most likely to benefit.
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Affiliation(s)
- Khaled Abdel-Kader
- Division of Nephrology and Hypertension, Vanderbilt University, 1161 21st Ave, S,, MCN S-3223, Nashville, TN 37232, USA.
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Greer RC, Crews DC, Boulware LE. Challenges perceived by primary care providers to educating patients about chronic kidney disease. J Ren Care 2013; 38:174-81. [PMID: 23176576 DOI: 10.1111/j.1755-6686.2012.00323.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To identify primary care providers' (PCPs) perceived barriers to educating patients about chronic kidney disease (CKD) during routine clinical visits. METHODS We conducted three focus groups of eighteen PCPs in Baltimore, Maryland (MD), USA. Focus groups began with the presentation of a hypothetical case of a patient with CKD, followed by open-ended questions to assess providers' perceived barriers to delivering education about CKD. Groups were audiotaped, transcribed and coded independently by two investigators who identified major themes. RESULTS PCPs reported on several patient, provider and system level barriers contributing to poor education about CKD in primary care that were both common and unique to barriers previously reported in educating patients regarding other chronic diseases. CONCLUSIONS Interventions designed to address barriers to CKD education identified by PCPs could improve the delivery of education about CKD in primary care settings.
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Affiliation(s)
- Raquel C Greer
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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McBride D, Dohan D, Handley MA, Powe NR, Tuot DS. Developing a CKD registry in primary care: provider attitudes and input. Am J Kidney Dis 2013; 63:577-83. [PMID: 24295612 DOI: 10.1053/j.ajkd.2013.10.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 10/09/2013] [Indexed: 11/11/2022]
Abstract
BACKGROUND Chronic disease registries have been successful at promoting the delivery of guideline-concordant primary care for patients with diabetes and hypertension, but not for chronic kidney disease (CKD). To understand whether a registry could be designed to improve CKD management in primary care, we explored primary care provider attitudes about the benefits (or lack thereof) of a CKD registry compared with other chronic diseases and the key facilitators of successfully implementing a CKD registry in safety-net primary care. STUDY DESIGN Qualitative, using semistructured interviews. SETTING & PARTICIPANTS We conducted and recorded semistructured 1-hour interviews with medical directors and quality improvement champions from safety-net adult primary care clinics in San Francisco. ANALYTIC APPROACH Recordings were transcribed and analyzed using a grounded theory approach until thematic saturation was achieved. RESULTS 20 primary care providers were interviewed. 4 themes relevant to the development of a successful CKD registry for safety-net primary care were identified: (1) provider beliefs that a CKD registry could aid in the delivery of team-based high-quality CKD care; (2) clinic workflow redesign and staffing are key facilitators to successful implementation of a CKD registry; (3) unique complexities of CKD, such as varying etiologies, may limit the use of a CKD registry by nonphysicians; and (4) a CKD registry is aligned with current primary care priorities and health care delivery strategies. LIMITATIONS Small sample size and reliance on clinician leaders within one health care delivery system. CONCLUSIONS A CKD registry directed at the entire health care team, with the functionality to track, standardize, and enhance CKD care through decision support, has the potential to improve the management of CKD in safety-net primary care settings. These data directly informed the development of a CKD registry in these settings in San Francisco.
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Affiliation(s)
| | - Daniel Dohan
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA; Department of Anthropology, History and Social Medicine, University of California, San Francisco, CA
| | - Margaret A Handley
- Division of General Internal Medicine at San Francisco General Hospital, University of California, San Francisco, CA; Center for Vulnerable Populations, San Francisco General Hospital, University of California San Francisco, San Francisco, CA
| | - Neil R Powe
- Division of General Internal Medicine at San Francisco General Hospital, University of California, San Francisco, CA; Center for Vulnerable Populations, San Francisco General Hospital, University of California San Francisco, San Francisco, CA
| | - Delphine S Tuot
- Division of Nephrology at San Francisco General Hospital, University of California San Francisco, San Francisco, CA.
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Fox CH, Vest BM, Kahn LS, Dickinson LM, Fang H, Pace W, Kimminau K, Vassalotti J, Loskutova N, Peterson K. Improving evidence-based primary care for chronic kidney disease: study protocol for a cluster randomized control trial for translating evidence into practice (TRANSLATE CKD). Implement Sci 2013; 8:88. [PMID: 23927603 PMCID: PMC3751479 DOI: 10.1186/1748-5908-8-88] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 07/17/2013] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) and end stage renal disease (ESRD) are steadily increasing in prevalence in the United States. While there is reasonable evidence that specific activities can be implemented by primary care physicians (PCPs) to delay CKD progression and reduce mortality, CKD is under-recognized and undertreated in primary care offices, and PCPs are generally not familiar with treatment guidelines. The current study addresses the question of whether the facilitated TRANSLATE model compared to computer decision support (CDS) alone will lead to improved evidence-based care for CKD in primary care offices. METHODS/DESIGN This protocol consists of a cluster randomized controlled trial (CRCT) followed by a process and cost analysis. Only practices providing ambulatory primary care as their principal function, located in non-hospital settings, employing at least one primary care physician, with a minimum of 2,000 patients seen in the prior year, are eligible. The intervention will occur at the cluster level and consists of providing CKD-specific CDS versus CKD-specific CDS plus practice facilitation for all elements of the TRANSLATE model. Patient-level data will be collected from each participating practice to examine adherence to guideline-concordant care, progression of CKD and all-cause mortality. Patients are considered to meet stage three CKD criteria if at least two consecutive estimated glomerular filtration rate (eGFR) measurements at least three months apart fall below 60 ml/min. The process evaluation (cluster level) will determine through qualitative methods the fidelity of the facilitated TRANSLATE program and find the challenges and enablers of the implementation process. The cost-effectiveness analysis will compare the benefit of the intervention of CDS alone against the intervention of CDS plus TRANSLATE (practice facilitation) in relationship to overall cost per quality adjusted years of life. DISCUSSION This study has three major innovations. First, this study adapts the TRANSLATE method, proven effective in diabetes care, to CKD. Second, we are creating a generalizable CDS specific to the Kidney Disease Outcome Quality Initiative (KDOQI) guidelines for CKD. Additionally, this study will evaluate the effects of CDS versus CDS with facilitation and answer key questions regarding the cost-effectiveness of a facilitated model for improving CKD outcomes. The study is testing virtual facilitation and Academic detailing making the findings generalizable to any area of the country. TRIAL REGISTRATION Registered as NCT01767883 on clinicaltrials.gov
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Affiliation(s)
- Chester H Fox
- Department of Family Medicine, State University of New York – University at Buffalo, 77 Goodell St, Buffalo, NY 14203, USA
| | - Bonnie M Vest
- Department of Family Medicine, State University of New York – University at Buffalo, 77 Goodell St, Buffalo, NY 14203, USA
| | - Linda S Kahn
- Department of Family Medicine, State University of New York – University at Buffalo, 77 Goodell St, Buffalo, NY 14203, USA
| | - L Miriam Dickinson
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Hai Fang
- Department of Health Systems, Management, and Policy, Colorado School of Public Health, University of Colorado Denver, Denver, CO, USA
| | - Wilson Pace
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- American Academy of Family Physicians National Research Network, Leawood, USA
| | - Kim Kimminau
- American Academy of Family Physicians National Research Network, Leawood, USA
- Department of Family Medicine, University of Kansas School of Medicine, Kansas, USA
| | - Joseph Vassalotti
- Division of Nephrology, Mount Sinai Medical Center, New York, USA
- National Kidney Foundation, New York, USA
| | - Natalia Loskutova
- American Academy of Family Physicians National Research Network, Leawood, USA
| | - Kevin Peterson
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota, USA
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Gilbert SJ, Parker MG, Norby SM. A decade after the KDOQI CKD guidelines: impact on medical education. Am J Kidney Dis 2012; 60:716-8. [PMID: 23067639 DOI: 10.1053/j.ajkd.2012.08.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 08/10/2012] [Indexed: 11/11/2022]
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Estrella MM, Sisson SD, Roth J, Choi MJ. Efficacy of an internet-based tool for improving physician knowledge of chronic kidney disease: an observational study. BMC Nephrol 2012; 13:126. [PMID: 23016990 PMCID: PMC3536684 DOI: 10.1186/1471-2369-13-126] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Accepted: 09/22/2012] [Indexed: 11/14/2022] Open
Abstract
Background Early recognition and management of chronic kidney disease (CKD) are associated with better outcomes. Internal medicine residency should prepare physicians to diagnose and manage CKD. Methods To examine whether residency training and program characteristics were associated with CKD knowledge and investigate the effectiveness of an internet-based training module in improving CKD knowledge, we analyzed data from CKD training modules administered annually to U.S. internal medicine residents from July 1, 2005 to June 30, 2009. Baseline CKD knowledge was assessed using pre-tests. The modules’ effectiveness was evaluated by post-tests. Comparisons were performed using X2 tests and paired t-tests. Results Of 4,702 residents, 38%, 33%, and 29% were program year (PGY)-1, PGY-2, and PGY-3, respectively. Baseline CKD knowledge was poor, with mean pre-test scores of 45.1-57.0% across the four years. The lowest pre-test performance was on CKD recognition. Pre-test scores were better with higher training levels (P-trend < 0.001 except 2005–2006 [P-trend = 0.35]). Affiliation with a renal fellowship program or program location within a region of high end-stage kidney disease prevalence was not associated with better baseline CKD knowledge. Completion of the CKD module led to significant improvements from pre- to post-test scores (mean improvement 27.8% [SD: 21.3%] which were consistent from 2005 to 2009. Conclusions Knowledge of diagnosis and management of CKD improves during residency training but remains poor among graduating residents. Web-based training can be effective in educating physicians on CKD-related issues. Studies are needed to determine whether knowledge gained from such an intervention translates to improved care of CKD patients.
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Affiliation(s)
- Michelle M Estrella
- Department of Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite 416, Baltimore, MD 21205, USA.
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Mula-Abed WAS, Al Rasadi K, Al-Riyami D. Estimated Glomerular Filtration Rate (eGFR): A Serum Creatinine-Based Test for the Detection of Chronic Kidney Disease and its Impact on Clinical Practice. Oman Med J 2012; 27:108-13. [PMID: 22496934 PMCID: PMC3321332 DOI: 10.5001/omj.2012.23] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Accepted: 03/03/2012] [Indexed: 12/20/2022] Open
Abstract
Chronic kidney disease (CKD) is an important epidemic and public health problem that is associated with a significant risk for vascular disease and early cardiovascular mortality as well as progression of kidney disease. Currently it is classified into five stages based on the glomerular filtration rate (GFR) as recommended by many professional guidelines. Radiolabelled methods for measuring GFR are accurate but not practical and can be used only on a very limited scale while the traditional methods require timed urine collection with its drawback of inaccuracy, cumbersomeness and inconvenience for the patients. However, the development of formula- based calculation of estimated GFR (eGFR) has offered a very practical and easy approach for converting serum creatinine value into GFR result taking into consideration patient's age, sex, ethnicity and weight (depending on equation type). The commonly used equations include Cockraft and Gault (1976), Modification of Diet in Renal Disease (MDRD) (1999) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) (2009). It is the implementation of these equations particularly the MDRD that has raised the medical awareness in the diagnosis and management of CKD and its adoption by many guidelines in North America and Europe. The impact and pitfalls of each of these equations in the screening, diagnosis and management of patients with CKD are presented and discussed in this review.
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Affiliation(s)
- Waad-Allah S. Mula-Abed
- Department of Chemical Pathology, Directorate of Laboratory Medicine and Pathology, Royal Hospital, Muscat, Sultanate of Oman
| | - Khalid Al Rasadi
- Department of Clinical Biochemistry, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | - Dawood Al-Riyami
- Department of Medicine, Nephrology Unit, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
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Identification and management of chronic kidney disease complications by internal medicine residents: a national survey. Am J Ther 2012; 18:e40-7. [PMID: 19918169 DOI: 10.1097/mjt.0b013e3181bbf6fc] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Many patients with chronic kidney disease (CKD) receive care from primary care physicians. Identification and management of CKD complications in primary care is suboptimal. It is not known if current residency curriculum adequately prepares a future internist in this aspect of CKD care. We performed an online questionnaire survey of internal medicine residents in the United States to determine knowledge of CKD complications and their management. Four hundred seventy-nine residents completed the survey with postgraduate year (PGY) distribution 166 PGY1, 187 PGY2, and 126 PGY3. Most of the residents correctly recognized anemia (91%) and bone disease (82%) as complications at estimated glomerular filtration rate less than 60 mL/min/1.73 m; however, only half of the residents identified coronary artery disease (54%) as a CKD complication. For a patient with estimated glomerular filtration rate less than 60 mL/min/1.73 m, two thirds of the residents would workup for anemia (62%), whereas half of them would check for mineral and bone disorder (56%). With regard to anemia of CKD, less than half of the residents knew the CKD goal hemoglobin level of 11 to 12 g/dL (44%); most would supplement iron stores (86%), whereas fewer would consider nephrology referral (28%). For mineral and bone disorders, many residents would recommend dietary phosphorus restriction (68%) and check 25-hydroxyvitamin D (62%); fewer residents would start 1,25-dihydroxyvitamin D (40%) or refer to the nephrologist (45%). Residents chose to discontinue angiotensin-converting enzyme inhibitor for medication-related complication of greater than 50% decline in estimated glomerular filtration rate (68%) and potassium greater than 5.5 mEq/L (93%). Mean performance score improved with increasing PGY (PGY1 59.4% ± 17.6%, PGY2 63.6% ± 15.6%, and PGY3 66.2% ± 16.5%; P = 0.002). Our study identified specific gaps in knowledge of CKD complications and management among internal medicine residents. Educational efforts such as instruction on use of CKD clinical practice guidelines may help raise awareness of CKD complications, benefits of early intervention, and improve CKD management.
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Coritsidis GN, Linden E, Stern AS. The role of the primary care physician in managing early stages of chronic kidney disease. Postgrad Med 2011; 123:177-85. [PMID: 21904100 DOI: 10.3810/pgm.2011.09.2473] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Recent increases in obesity, diabetes, and hypertension, along with the aging of the US population, are driving a dramatic rise in the prevalence of chronic kidney disease (CKD). Despite this increase, the majority of Americans with early-stage CKD remain unaware of their disease. Primary care physicians are at the forefront of efforts for early recognition of CKD and management to control its progression. Patients with CKD should be referred to nephrologists no later than the point at which their estimated glomerular filtration rate reaches 30 mL/min. Nephrology evaluation at this point is essential to facilitate timely preparation for care of end-stage renal disease through preemptive transplantation or planned transition to dialysis. In addition to stringent control of underlying hypertension and/or diabetes, mineral metabolic parameters (serum parathyroid hormone, phosphorus, calcium, and bicarbonate) in patients with advancing CKD should be managed closely to avoid adverse effects on the cardiovascular and skeletal systems.
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Tuot DS, Plantinga LC, Hsu CY, Jordan R, Burrows NR, Hedgeman E, Yee J, Saran R, Powe NR. Chronic kidney disease awareness among individuals with clinical markers of kidney dysfunction. Clin J Am Soc Nephrol 2011; 6:1838-44. [PMID: 21784832 DOI: 10.2215/cjn.00730111] [Citation(s) in RCA: 109] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Awareness of chronic kidney disease (CKD) among providers and patients is low. Whether clinical cues prompt recognition of CKD is unknown. We examined whether markers of kidney disease that should trigger CKD recognition among providers are associated with higher individual CKD awareness. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS CKD awareness was assessed in 1852 adults with an estimated GFR <60 ml/min per 1.73 m(2) using 1999 to 2008 National Health and Nutrition Examination Survey data. CKD awareness was a "yes" answer to "Have you ever been told you have weak or failing kidneys?" Participants were grouped by distribution of the following abnormal markers of CKD: hyperkalemia, acidosis, hyperphosphatemia, elevated blood urea nitrogen, anemia, albuminuria, and uncontrolled hypertension. Odds of CKD awareness associated with each abnormal marker and groupings of markers were estimated by multivariable logistic regression. RESULTS Among individuals with kidney disease, only those with albuminuria had greater odds of CKD awareness (adjusted odds ratio, 4.0, P < 0.01) than those without. Odds of CKD awareness increased with each additional manifested clinical marker of CKD (adjusted odds ratio, 1.3, P = 0.05). Nonetheless, 90% of individuals with two to four markers of CKD and 84% of individuals with ≥5 markers of CKD were unaware of their disease. CONCLUSIONS Although individuals who manifest many markers of kidney dysfunction are more likely to be aware of their CKD, their CKD awareness remains low. A better understanding of mechanisms of awareness is required to facilitate earlier detection of CKD and implement therapy to minimize associated complications.
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Affiliation(s)
- Delphine S Tuot
- 521 Parnassus Avenue, Clinical Science Building C-443, Box 0532, Division of Nephrology, University of California, San Francisco, San Francisco, CA 94143, USA.
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Agrawal V, Garimella PS, Roshan SJ, Ghosh AK. Questionnaire survey of physicians: Design and practical use in nephrology. Indian J Nephrol 2011; 19:41-7. [PMID: 20368922 PMCID: PMC2847806 DOI: 10.4103/0971-4065.53320] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
As medicine grows in complexity, it is imperative for physicians to update their knowledge base and practice to reflect current standards of care. Postgraduate training offers a golden opportunity for resident physicians to create a strong foundation of concepts in medicine. There is a need for assessing the knowledge of residents regarding established clinical practice guidelines and their perceptions regarding patient care and management. In this paper, we review how questionnaire surveys can be designed and applied to identify significant gaps in resident knowledge and inappropriate attitudes and beliefs. This evaluation has important implications for program directors who can then initiate measures to improve resident education. Such efforts during residency training have the potential of improving patient outcomes. We discuss the design of the questionnaire, its pre-testing and validity measures, online distribution, efficient response collection, data analysis, and possible future research. Finally, we illustrate this method of educational research with a questionnaire survey designed to measure the awareness of chronic kidney disease among internal medicine residents.
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Affiliation(s)
- Varun Agrawal
- Department of Internal Medicine, William Beaumont Hospital, Royal Oak, Michigan, USA
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Greer RC, Cooper LA, Crews DC, Powe NR, Boulware LE. Quality of patient-physician discussions about CKD in primary care: a cross-sectional study. Am J Kidney Dis 2011; 57:583-91. [PMID: 21131116 PMCID: PMC4374349 DOI: 10.1053/j.ajkd.2010.08.027] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2010] [Accepted: 08/25/2010] [Indexed: 11/11/2022]
Abstract
BACKGROUND The quality of patient-physician discussions about chronic kidney disease (CKD) in primary care has not been studied previously. STUDY DESIGN Cross-sectional study. SETTINGS & PARTICIPANTS We audiotaped encounters between 236 patients with hypertension and their primary care physicians (n = 40). PREDICTORS Patient, physician, and encounter characteristics. OUTCOMES & MEASUREMENTS We described the occurrence and characteristics (content, use of technical terms, and physician assessment of patient comprehension of new concepts) of CKD discussions. We assessed patient and physician characteristics associated with CKD discussion occurrence. RESULTS Many patients (mean age, 59 years) had uncontrolled hypertension (51%), diabetes (44%), and/or 3 or more comorbid conditions (51%). Most primary care physicians practiced (52%) fewer than 10 years. CKD discussions occurred in few (26%; n = 61) encounters, with content focused on laboratory assessment (89%), risk-factor treatment (28%), and causes (26%) of CKD. In encounters that included a CKD discussion, physicians used technical terms (28%; n = 17) and rarely assessed patients' comprehension (2%; n = 1). CKD discussions were statistically significantly less common in visits of patients with some (vs no) college education (OR, 0.23; 95% CI, 0.09-0.56), with 3 or more (vs fewer) comorbid conditions (OR, 0.49; 95% CI, 0.25-0.96), and who saw physicians with more (vs fewer) than 10 years of practice experience (OR, 0.41; 95% CI, 0.21-0.80). CKD discussions were more common during longer encounters (OR, 1.31; 95% CI, 1.04-1.65) and encounters in which diabetes was (vs was not) discussed (OR, 2.87; 95% CI, 1.22-6.77). LIMITATIONS Generalizability of our findings may be limited. CONCLUSIONS Patient-physician discussions about CKD in high-risk primary care patients were infrequent. Physicians used technical terms and infrequently assessed patients' understanding of new CKD concepts. Efforts to improve the frequency and content of patient-physician CKD discussions in primary care could improve patients' clinical outcomes.
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Affiliation(s)
- Raquel C Greer
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, 2024 E. Monument Street, Baltimore, MD 21287, USA.
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Vigoda MM, Sweitzer B, Miljkovic N, Arheart KL, Messinger S, Candiotti K, Lubarsky D. 2007 American College of Cardiology/American Heart Association (ACC/AHA) Guidelines on Perioperative Cardiac Evaluation Are Usually Incorrectly Applied by Anesthesiology Residents Evaluating Simulated Patients. Anesth Analg 2011; 112:940-9. [DOI: 10.1213/ane.0b013e31820a1457] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Do Americans receive high-value health care? Value only improves by advancing key indicators in one of two directions: increasing quality, decreasing cost, or both. In the face of unyielding mortality rates and the relentless expense of end-stage renal disease, government agencies and professional organizations are now focusing on new quality measures for patients with advancing chronic kidney disease. These performance measures are in early stages of refinement but reflect efforts of payers to slow the incidence of progressive renal disease across the population. To improve quality of care, one must study the performance measures themselves and determine how to capture the necessary data efficiently, identify the appropriate patients for measurement, and assign accountability to providers. Here, we discuss the challenges of doing this well.
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Affiliation(s)
- Kimberly A Smith
- University of Michigan, 6312 Medical Science Building I, 1150 W. Medical Center Drive, Ann Arbor, Michigan 48109-5604, USA.
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McCullough PA, Steigerwalt S, Tolia K, Chen SC, Li S, Norris KC, Whaley-Connell A. Cardiovascular disease in chronic kidney disease: data from the Kidney Early Evaluation Program (KEEP). Curr Diab Rep 2011; 11:47-55. [PMID: 21076895 PMCID: PMC3206095 DOI: 10.1007/s11892-010-0162-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Diabetes mellitus (DM) and hypertension (HTN) are leading joint risk factors for both cardiovascular disease (CVD) and chronic kidney disease (CKD). In the nationwide KEEP (Kidney Early Evaluation Program) an estimated glomerular filtration rate less than 60 mL/min/1.73 m(2) or a urine albumin:creatinine ratio ≥30 mg/g (3.4 mg/mmol) defines CKD. Overall in KEEP, the rates of identified CKD and self-reported CVD are 25.7% and 22.1%, respectively. The presence of CKD has been associated with younger ages of self-reported myocardial infarction and stroke. The combination of CVD and CKD in KEEP has been associated with shorter survival time. Finally, the presence of CVD or a prior history of coronary revascularization has been associated with modestly better rates of CVD risk factor control; however, the majority of patients with CKD have suboptimally controlled blood pressure, glucose, or lipids. These data suggest that patients with CKD are not only at higher risk for CVD and subsequent mortality, but are also ideal for targeted community--and practice-based interventions to improve risk factor control and, hopefully, reduce rates of subsequent cardiovacular events.
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Affiliation(s)
- Peter A McCullough
- Department of Medicine, Sections of Cardiology, Nephrology, and Endocrinology, St. John Providence Health System, Providence Park Hospital, Novi, MI, USA.
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Greer RC, Powe NR, Jaar BG, Troll MU, Boulware LE. Effect of primary care physicians' use of estimated glomerular filtration rate on the timing of their subspecialty referral decisions. BMC Nephrol 2011; 12:1. [PMID: 21235763 PMCID: PMC3033812 DOI: 10.1186/1471-2369-12-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Accepted: 01/14/2011] [Indexed: 01/13/2023] Open
Abstract
Background Primary care providers' suboptimal recognition of the severity of chronic kidney disease (CKD) may contribute to untimely referrals of patients with CKD to subspecialty care. It is unknown whether U.S. primary care physicians' use of estimated glomerular filtration rate (eGFR) rather than serum creatinine to estimate CKD severity could improve the timeliness of their subspecialty referral decisions. Methods We conducted a cross-sectional study of 154 United States primary care physicians to assess the effect of use of eGFR (versus creatinine) on the timing of their subspecialty referrals. Primary care physicians completed a questionnaire featuring questions regarding a hypothetical White or African American patient with progressing CKD. We asked primary care physicians to identify the serum creatinine and eGFR levels at which they would recommend patients like the hypothetical patient be referred for subspecialty evaluation. We assessed significant improvement in the timing [from eGFR < 30 to ≥ 30 mL/min/1.73m2) of their recommended referrals based on their use of creatinine versus eGFR. Results Primary care physicians recommended subspecialty referrals later (CKD more advanced) when using creatinine versus eGFR to assess kidney function [median eGFR 32 versus 55 mL/min/1.73m2, p < 0.001]. Forty percent of primary care physicians significantly improved the timing of their referrals when basing their recommendations on eGFR. Improved timing occurred more frequently among primary care physicians practicing in academic (versus non-academic) practices or presented with White (versus African American) hypothetical patients [adjusted percentage(95% CI): 70% (45-87) versus 37% (reference) and 57% (39-73) versus 25% (reference), respectively, both p ≤ 0.01). Conclusions Primary care physicians recommended subspecialty referrals earlier when using eGFR (versus creatinine) to assess kidney function. Enhanced use of eGFR by primary care physicians' could lead to more timely subspecialty care and improved clinical outcomes for patients with CKD.
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Affiliation(s)
- Raquel C Greer
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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