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Stewart S, Kalra PA, Blakeman T, Kontopantelis E, Cranmer-Gordon H, Sinha S. Chronic kidney disease: detect, diagnose, disclose-a UK primary care perspective of barriers and enablers to effective kidney care. BMC Med 2024; 22:331. [PMID: 39148079 PMCID: PMC11328380 DOI: 10.1186/s12916-024-03555-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Accepted: 08/05/2024] [Indexed: 08/17/2024] Open
Abstract
Chronic kidney disease (CKD) is a global public health problem with major human and economic consequences. Despite advances in clinical guidelines, classification systems and evidence-based treatments, CKD remains underdiagnosed and undertreated and is predicted to be the fifth leading cause of death globally by 2040. This review aims to identify barriers and enablers to the effective detection, diagnosis, disclosure and management of CKD since the introduction of the Kidney Disease Outcomes Quality Initiative (KDOQI) classification in 2002, advocating for a renewed approach in response to updated Kidney Disease: Improving Global Outcomes (KDIGO) 2024 clinical guidelines. The last two decades of improvements in CKD care in the UK are underpinned by international adoption of the KDIGO classification system, mixed adoption of evidence-based treatments and research informed clinical guidelines and policy. Interpretation of evidence within clinical and academic communities has stimulated significant debate of how best to implement such evidence which has frequently fuelled and frustratingly forestalled progress in CKD care. Key enablers of effective CKD care include clinical classification systems (KDIGO), evidence-based treatments, electronic health record tools, financially incentivised care, medical education and policy changes. Barriers to effective CKD care are extensive; key barriers include clinician concerns regarding overdiagnosis, a lack of financially incentivised care in primary care, complex clinical guidelines, managing CKD in the context of multimorbidity, bureaucratic burden in primary care, underutilisation of sodium-glucose co-transporter-2 inhibitor (SGLT2i) medications, insufficient medical education in CKD, and most recently - a sustained disruption to routine CKD care during and after the COVID-19 pandemic. Future CKD care in UK primary care must be informed by lessons of the last two decades. Making step change, over incremental improvements in CKD care at scale requires a renewed approach that addresses key barriers to detection, diagnosis, disclosure and management across traditional boundaries of healthcare, social care, and public health. Improved coding accuracy in primary care, increased use of SGLT2i medications, and risk-based care offer promising, cost-effective avenues to improve patient and population-level kidney health. Financial incentives generally improve achievement of care quality indicators - a review of financial and non-financial incentives in CKD care is urgently needed.
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Affiliation(s)
- Stuart Stewart
- The University of Manchester, Centre for Primary Care & Health Services Research, Manchester, UK.
- Donal O'Donoghue Renal Research Centre, Northern Care Alliance NHS Foundation Trust, Manchester, UK.
- Rochdale Care Organisation, Northern Care Alliance NHS Foundation Trust, Manchester, UK.
| | - Philip A Kalra
- Donal O'Donoghue Renal Research Centre, Northern Care Alliance NHS Foundation Trust, Manchester, UK
| | - Tom Blakeman
- The University of Manchester, Centre for Primary Care & Health Services Research, Manchester, UK
| | - Evangelos Kontopantelis
- The University of Manchester, Centre for Primary Care & Health Services Research, Manchester, UK
| | - Howard Cranmer-Gordon
- Donal O'Donoghue Renal Research Centre, Northern Care Alliance NHS Foundation Trust, Manchester, UK
| | - Smeeta Sinha
- Donal O'Donoghue Renal Research Centre, Northern Care Alliance NHS Foundation Trust, Manchester, UK
- Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
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Toyama M, Satoh M, Nakayama S, Hashimoto H, Muroya T, Murakami T, Hirose T, Obara T, Nakaya N, Mori T, Ohkubo T, Imai Y, Hozawa A, Metoki H. Combined effects of blood pressure and glucose status on the risk of chronic kidney disease. Hypertens Res 2024; 47:1831-1841. [PMID: 38671217 PMCID: PMC11224015 DOI: 10.1038/s41440-024-01683-x] [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: 09/07/2023] [Revised: 03/24/2024] [Accepted: 03/31/2024] [Indexed: 04/28/2024]
Abstract
This study aimed to assess the combined effects of blood pressure (BP) and glucose status on chronic kidney disease (CKD) incidence in young and middle-aged adults. We examined data from 1,297,341 Japanese individuals aged <60 years (60.1% men; mean age 41.4 ± 9.3 years) with no history of CKD at baseline. The interval-censored Cox proportional hazards model with covariates was used. During a median follow-up period of 2.1 years, new onset CKD (estimated glomerular filtration rate <60 ml/min/1.73 m2 and/or proteinuria) occurred in 80,187 participants. In participants without antihypertensive treatment (AHT), the adjusted hazard ratios (95% confidence interval) per 1-standard deviation, that is, 15 mmHg increase in systolic BP for CKD incidence, were 1.08 (1.07-1.09), 1.12 (1.10-1.13), and 1.15 (1.12-1.18) in normoglycemia, borderline glycemia, and diabetes groups, respectively. These ratios were significantly higher in the borderline glycemia and diabetes groups compared with those in the normoglycemia group (interaction p < 0.0001). The interaction between BP and borderline glycemia was evident when the outcome definition was restricted to proteinuria. In participants under AHT, systolic BP was most strongly associated with CKD risk in the diabetes group, although no significant interaction was observed. High BP and high glucose status may synergistically increase the incidence of CKD. Strict BP management may play an important role in the early prevention of CKD in individuals with worse glucose status within the young and middle-aged population. This large-scale longitudinal cohort study showed high BP and diabetes synergistically increased the risk of CKD in individuals without AHT. Strict BP management may play an important role in the early prevention of CKD in individuals with worse glucose status within the young and middle-aged population.
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Affiliation(s)
- Maya Toyama
- Department of Preventive Medicine and Epidemiology, Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
- Division of Public Health, Hygiene and Epidemiology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
- Department of Nephrology, Self-Defense Forces Sendai Hospital, Sendai, Japan
| | - Michihiro Satoh
- Department of Preventive Medicine and Epidemiology, Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan.
- Division of Public Health, Hygiene and Epidemiology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan.
- Department of Pharmacy, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Japan.
| | - Shingo Nakayama
- Division of Public Health, Hygiene and Epidemiology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
- Division of Nephrology and Endocrinology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Hideaki Hashimoto
- Department of Preventive Medicine and Epidemiology, Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
- Division of Public Health, Hygiene and Epidemiology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
- Division of Nephrology and Endocrinology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Tomoko Muroya
- Division of Public Health, Hygiene and Epidemiology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
- Division of Internal Medicine, Izumi Hospital, Sendai, Japan
| | - Takahisa Murakami
- Department of Preventive Medicine and Epidemiology, Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
- Division of Public Health, Hygiene and Epidemiology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
- Division of Aging and Geriatric Dentistry, Department of Rehabilitation Dentistry, Tohoku University Graduate School of Dentistry, Sendai, Japan
| | - Takuo Hirose
- Division of Nephrology and Endocrinology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
- Department of Endocrinology and Applied Medical Science, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Taku Obara
- Department of Preventive Medicine and Epidemiology, Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
- Department of Pharmaceutical Sciences, Tohoku University Hospital, Sendai, Japan
| | - Naoki Nakaya
- Department of Preventive Medicine and Epidemiology, Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
| | - Takefumi Mori
- Division of Nephrology and Endocrinology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Takayoshi Ohkubo
- Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan
- Tohoku Institute for Management of Blood Pressure, Sendai, Japan
| | - Yutaka Imai
- Tohoku Institute for Management of Blood Pressure, Sendai, Japan
| | - Atsushi Hozawa
- Department of Preventive Medicine and Epidemiology, Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
| | - Hirohito Metoki
- Division of Public Health, Hygiene and Epidemiology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
- Tohoku Institute for Management of Blood Pressure, Sendai, Japan
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Sammut-Powell C, Sisk R, Vazquez-Mendez E, Vasnawala H, Goncalves S, Edge M, Cameron R. Global Validation of a Model to Predict Reduced Estimated GFR in People With Type 2 Diabetes Without Diagnosis of CKD. Kidney Int Rep 2024; 9:2047-2055. [PMID: 39081746 PMCID: PMC11284396 DOI: 10.1016/j.ekir.2024.04.005] [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: 08/13/2023] [Revised: 03/31/2024] [Accepted: 04/01/2024] [Indexed: 08/02/2024] Open
Abstract
Introduction A minimal-resource model for predicting reduced kidney function among people with type 2 diabetes and no diagnosis of chronic kidney disease (CKD) stages 3 to 5 was previously developed in a UK population to pre-screen for undiagnosed CKD. This study aims to evaluate the performance of the model on a global population and assess its adequacy with and without regional adjustment. Methods A retrospective observational study was performed using data collected from the iCaReMe global registry (NCT03549754) and the DISCOVER study (NCT02322762 and NCT02226822). Patients were grouped by their World Health Organization classified region. An estimated glomerular filtration rate (eGFR) <60 ml/min per 1.73 m2 was the marker of reduced kidney function. A regional-intercept recalibration was applied to adjust for regional variation. Discrimination and calibration were evaluated for the UK-developed and recalibrated models. Results A total of 14,180 patients (46 countries, 6 regions) were identified with type 2 diabetes, no previous diagnosis of CKD stages 3 to 5, and had a serum creatinine measurement or eGFR recorded. The UK model underestimated risk when applied globally and was deemed inadequate. The model with regional adjustment achieved the target sensitivity (80.5%; 95% confidence interval [CI]: 78.8%-82.3%) and demonstrated a relative improvement of 51.5% (95% CI: 48.1%-55.1%) in the positive predictive value (PPV), compared to a screen-all approach. Conclusion The regional-adjusted model demonstrated adequate performance globally. Incorporating the model within practice could help clinicians to risk-stratify and prioritize patients at high risk. This could enable improved efficiency via risk-tailored screening, particularly in lower-middle-income countries (LMICs).
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Santhakumaran S, Fisher L, Zheng B, Mahalingasivam V, Plumb L, Parker EPK, Steenkamp R, Morton C, Mehrkar A, Bacon S, Lyon S, Konstant-Hambling R, Goldacre B, MacKenna B, Tomlinson LA, Nitsch D. Identification of patients undergoing chronic kidney replacement therapy in primary and secondary care data: validation study based on OpenSAFELY and UK Renal Registry. BMJ MEDICINE 2024; 3:e000807. [PMID: 38645891 PMCID: PMC11029353 DOI: 10.1136/bmjmed-2023-000807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 03/19/2024] [Indexed: 04/23/2024]
Abstract
Objective To validate primary and secondary care codes in electronic health records to identify people receiving chronic kidney replacement therapy based on gold standard registry data. Design Validation study using data from OpenSAFELY and the UK Renal Registry, with the approval of NHS England. Setting Primary and secondary care electronic health records from people registered at 45% of general practices in England on 1 January 2020, linked to data from the UK Renal Registry (UKRR) within the OpenSAFELY-TPP platform, part of the NHS England OpenSAFELY covid-19 service. Participants 38 745 prevalent patients (recorded as receiving kidney replacement therapy on 1 January 2020 in UKRR data, or primary or secondary care data) and 10 730 incident patients (starting kidney replacement therapy during 2020), from a population of 19 million people alive and registered with a general practice in England on 1 January 2020. Main outcome measures Sensitivity and positive predictive values of primary and secondary care code lists for identifying prevalent and incident kidney replacement therapy cohorts compared with the gold standard UKRR data on chronic kidney replacement therapy. Agreement across the data sources overall, and by treatment modality (transplantation or dialysis) and personal characteristics. Results Primary and secondary care code lists were sensitive for identifying the UKRR prevalent cohort (91.2% (95% confidence interval (CI) 90.8% to 91.6%) and 92.0% (91.6% to 92.4%), respectively), but not the incident cohort (52.3% (50.3% to 54.3%) and 67.9% (66.1% to 69.7%)). Positive predictive values were low (77.7% (77.2% to 78.2%) for primary care data and 64.7% (64.1% to 65.3%) for secondary care data), particularly for chronic dialysis (53.7% (52.9% to 54.5%) for primary care data and 49.1% (48.0% to 50.2%) for secondary care data). Sensitivity decreased with age and index of multiple deprivation in primary care data, but the opposite was true in secondary care data. Agreement was lower in children, with 30% (295/980) featuring in all three datasets. Half (1165/2315) of the incident patients receiving dialysis in UKRR data had a kidney replacement therapy code in the primary care data within three months of the start date of the kidney replacement therapy. No codes existed whose exclusion would substantially improve the positive predictive value without a decrease in sensitivity. Conclusions Codes used in primary and secondary care data failed to identify a small proportion of prevalent patients receiving kidney replacement therapy. Codes also identified many patients who were not recipients of chronic kidney replacement therapy in UKRR data, particularly dialysis codes. Linkage with UKRR kidney replacement therapy data facilitated more accurate identification of incident and prevalent kidney replacement therapy cohorts for research into this vulnerable population. Poor coding has implications for any patient care (including eligibility for vaccination, resourcing, and health policy responses in future pandemics) that relies on accurate reporting of kidney replacement therapy in primary and secondary care data.
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Affiliation(s)
| | - Louis Fisher
- Bennett Institute for Applied Data Science, University of Oxford, Oxford, UK
| | - Bang Zheng
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Lucy Plumb
- UK Renal Registry, UK Kidney Association, Bristol, UK
- Population Health Science Institute, University of Bristol, Bristol, UK
| | | | | | - Caroline Morton
- Bennett Institute for Applied Data Science, University of Oxford, Oxford, UK
| | - Amir Mehrkar
- Bennett Institute for Applied Data Science, University of Oxford, Oxford, UK
| | - Sebastian Bacon
- Bennett Institute for Applied Data Science, University of Oxford, Oxford, UK
| | - Sue Lyon
- UKKA Patient Council, UK Kidney Association, Bristol, UK
| | | | - Ben Goldacre
- Bennett Institute for Applied Data Science, University of Oxford, Oxford, UK
| | - Brian MacKenna
- Bennett Institute for Applied Data Science, University of Oxford, Oxford, UK
| | | | - Dorothea Nitsch
- UK Renal Registry, UK Kidney Association, Bristol, UK
- London School of Hygiene and Tropical Medicine, London, UK
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Chesnaye NC, Carrero JJ, Hecking M, Jager KJ. Differences in the epidemiology, management and outcomes of kidney disease in men and women. Nat Rev Nephrol 2024; 20:7-20. [PMID: 37985869 DOI: 10.1038/s41581-023-00784-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2023] [Indexed: 11/22/2023]
Abstract
Improved understanding of differences in kidney disease epidemiology, management and outcomes in men and women could help nephrologists to better meet the needs of their patients from a sex- and gender-specific perspective. Evidence of sex differences in the risk and outcomes of acute kidney injury is mixed and dependent on aetiology. Women have a higher prevalence of chronic kidney disease (CKD) stages 3-5 than men, whereas men have a higher prevalence of albuminuria and hence CKD stages 1-2. Men show a faster decline in kidney function, progress more frequently to kidney failure and have higher mortality and risk of cardiovascular disease than women. However, the protective effect of female sex is reduced with CKD progression. Women are less likely than men to be aware of, screened for and diagnosed with CKD, started on antiproteinuric medication and referred to nephrologist care. They also consistently report a poorer health-related quality of life and a higher symptom burden than men. Women experience greater barriers than men to access the waiting list for kidney transplantation, particularly with respect to older age and obesity. However, women also have longer survival than men after transplantation, which may partly explain the comparable prevalence of transplantation between the sexes.
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Affiliation(s)
- Nicholas C Chesnaye
- ERA Registry, Amsterdam UMC location University of Amsterdam, Medical Informatics, Amsterdam, Netherlands
- Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, the Netherlands
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Division of Nephrology, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Manfred Hecking
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
- Department of Epidemiology, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Kitty J Jager
- ERA Registry, Amsterdam UMC location University of Amsterdam, Medical Informatics, Amsterdam, Netherlands.
- Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, the Netherlands.
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Swartling O, Evans M, Larsson P, Perri G, Yarbakht D, Al-Kamil H, Gilg S, Holmberg M, Sparrelid E, Ghorbani P. Preoperative chronic kidney disease and complications after pancreatoduodenectomy: a retrospective cohort study. ANZ J Surg 2023; 93:2492-2498. [PMID: 37654154 DOI: 10.1111/ans.18677] [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: 12/14/2022] [Revised: 08/01/2023] [Accepted: 08/17/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Chronic kidney disease is a prevalent condition in surgical patients. Possible associations with increased postoperative morbidity and mortality have not been clearly demonstrated in patients undergoing pancreatoduodenectomy. The aim of this study was to assess the risk of postoperative complications in patients with reduced kidney function undergoing pancreatoduodenectomy. METHODS All patients undergoing pancreatoduodenectomy at Karolinska University Hospital between 2008 and 2019 were retrospectively included. The variable of interest was chronic kidney disease, based on preoperative estimated glomerular filtration rate measurements. Unadjusted and adjusted logistic regression analyses were performed for standardized postoperative complications. RESULTS A total of 971 patients were included in the study, of whom 92 (10%) had an estimated glomerular filtration rate < 60 mL/min/1.73m2 , equivalent to chronic kidney disease Stage 3a or worse. Patients with chronic kidney disease had a higher odds of longer hospital stay (adjusted odds ratio 1.58, 95% confidence interval 1.00-2.50) and postoperative weight increase (adjusted odds ratio 2.02, 1.14-3.56). A 10 unit increase of preoperative estimated glomerular filtration rate was associated to lower odds of intensive care unit admission (adjusted odds ratio 0.81, 0.69-0.95), delayed gastric emptying (adjusted odds ratio 0.90, 0.81-0.99), and post-operative pancreatic fistula (adjusted odds ratio 0.83, 0.74-0.94). CONCLUSION Patients undergoing pancreatoduodenectomy with decreased preoperative kidney function are more likely to experience major postoperative complications, and also postoperative weight increase. Preoperative kidney function assessment is important in risk stratification before pancreatoduodenectomies.
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Affiliation(s)
- Oskar Swartling
- Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Marie Evans
- Renal Unit, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Patrik Larsson
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Giampaolo Perri
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Danial Yarbakht
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Hussein Al-Kamil
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Stefan Gilg
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Marcus Holmberg
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Ernesto Sparrelid
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Poya Ghorbani
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden
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Taylor DM, Nimmo AM, Caskey FJ, Johnson R, Pippias M, Melendez-Torres G. Complex Interventions Across Primary and Secondary Care to Optimize Population Kidney Health: A Systematic Review and Realist Synthesis to Understand Contexts, Mechanisms, and Outcomes. Clin J Am Soc Nephrol 2023; 18:563-572. [PMID: 36888919 PMCID: PMC10278806 DOI: 10.2215/cjn.0000000000000136] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 02/22/2023] [Indexed: 03/10/2023]
Abstract
BACKGROUND CKD affects 850 million people worldwide and is associated with high risk of kidney failure and death. Existing, evidence-based treatments are not implemented in at least a third of eligible patients, and there is socioeconomic inequity in access to care. While interventions aiming to improve delivery of evidence-based care exist, these are often complex, with intervention mechanisms acting and interacting in specific contexts to achieve desired outcomes. METHODS We undertook realist synthesis to develop a model of these context-mechanism-outcome interactions. We included references from two existing systematic reviews and from database searches. Six reviewers produced a long list of study context-mechanism-outcome configurations based on review of individual studies. During group sessions, these were synthesized to produce an integrated model of intervention mechanisms, how they act and interact to deliver desired outcomes, and in which contexts these mechanisms work. RESULTS Searches identified 3371 relevant studies, of which 60 were included, most from North America and Europe. Key intervention components included automated detection of higher-risk cases in primary care with management advice to general practitioners, educational support, and non-patient-facing nephrologist review. Where successful, these components promote clinician learning during the process of managing patients with CKD, promote clinician motivation to take steps toward evidence-based CKD management, and integrate dynamically with existing workflows. These mechanisms have the potential to result in improved population kidney disease outcomes and cardiovascular outcomes in supportive contexts (organizational buy-in, compatibility of interventions, geographical considerations). However, patient perspectives were unavailable and therefore did not contribute to our findings. CONCLUSIONS This systematic review and realist synthesis describes how complex interventions work to improve delivery of CKD care, providing a framework within which future interventions can be developed. Included studies provided insight into the functioning of these interventions, but patient perspectives were lacking in available literature. PODCAST This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_05_08_CJN0000000000000136.mp3.
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Affiliation(s)
- Dominic M. Taylor
- Renal Service, North Bristol NHS Trust, United Kingdom
- Population Health Sciences, Bristol Medical School, University of Bristol, United Kingdom
| | - Ailish M. Nimmo
- Renal Service, North Bristol NHS Trust, United Kingdom
- Population Health Sciences, Bristol Medical School, University of Bristol, United Kingdom
| | - Fergus J. Caskey
- Renal Service, North Bristol NHS Trust, United Kingdom
- Population Health Sciences, Bristol Medical School, University of Bristol, United Kingdom
| | - Rachel Johnson
- Population Health Sciences, Bristol Medical School, University of Bristol, United Kingdom
| | - Maria Pippias
- Renal Service, North Bristol NHS Trust, United Kingdom
- Population Health Sciences, Bristol Medical School, University of Bristol, United Kingdom
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8
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Parker EP, Tazare J, Hulme WJ, Bates C, Carr EJ, Cockburn J, Curtis HJ, Fisher L, Green AC, Harper S, Hester F, Horne EM, Loud F, Lyon S, Mahalingasivam V, Mehrkar A, Nab L, Parry J, Santhakumaran S, Steenkamp R, Sterne JA, Walker AJ, Williamson EJ, Willicombe M, Zheng B, Goldacre B, Nitsch D, Tomlinson LA. Factors associated with COVID-19 vaccine uptake in people with kidney disease: an OpenSAFELY cohort study. BMJ Open 2023; 13:e066164. [PMID: 36720568 PMCID: PMC9890277 DOI: 10.1136/bmjopen-2022-066164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 01/06/2023] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE To characterise factors associated with COVID-19 vaccine uptake among people with kidney disease in England. DESIGN Retrospective cohort study using the OpenSAFELY-TPP platform, performed with the approval of NHS England. SETTING Individual-level routine clinical data from 24 million people across GPs in England using TPP software. Primary care data were linked directly with COVID-19 vaccine records up to 31 August 2022 and with renal replacement therapy (RRT) status via the UK Renal Registry (UKRR). PARTICIPANTS A cohort of adults with stage 3-5 chronic kidney disease (CKD) or receiving RRT at the start of the COVID-19 vaccine roll-out was identified based on evidence of reduced estimated glomerular filtration rate (eGFR) or inclusion in the UKRR. MAIN OUTCOME MEASURES Dose-specific vaccine coverage over time was determined from 1 December 2020 to 31 August 2022. Individual-level factors associated with receipt of a 3-dose or 4-dose vaccine series were explored via Cox proportional hazards models. RESULTS 992 205 people with stage 3-5 CKD or receiving RRT were included. Cumulative vaccine coverage as of 31 August 2022 was 97.5%, 97.0% and 93.9% for doses 1, 2 and 3, respectively, and 81.9% for dose 4 among individuals with one or more indications for eligibility. Delayed 3-dose vaccine uptake was associated with younger age, minority ethnicity, social deprivation and severe mental illness-associations that were consistent across CKD severity subgroups, dialysis patients and kidney transplant recipients. Similar associations were observed for 4-dose uptake. CONCLUSION Although high primary vaccine and booster dose coverage has been achieved among people with kidney disease in England, key disparities in vaccine uptake remain across clinical and demographic groups and 4-dose coverage is suboptimal. Targeted interventions are needed to identify barriers to vaccine uptake among under-vaccinated subgroups identified in the present study.
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Affiliation(s)
| | - John Tazare
- London School of Hygiene & Tropical Medicine, London, UK
| | - William J Hulme
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | | | | | | | - Helen J Curtis
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Louis Fisher
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Amelia Ca Green
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | | | | | - Elsie Mf Horne
- Population Health Sciences, University of Bristol, Bristol, UK
- NIHR Bristol Biomedical Research Centre, Bristol, UK
| | | | | | | | - Amir Mehrkar
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Linda Nab
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | | | | | | | - Jonathan Ac Sterne
- Population Health Sciences, University of Bristol, Bristol, UK
- NIHR Bristol Biomedical Research Centre, Bristol, UK
- Health Data Research UK South-West, Bristol, UK
| | - Alex J Walker
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | | | - Michelle Willicombe
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, UK
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Bang Zheng
- London School of Hygiene & Tropical Medicine, London, UK
| | - Ben Goldacre
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Dorothea Nitsch
- London School of Hygiene & Tropical Medicine, London, UK
- UK Renal Registry, Bristol, UK
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Jones JL, Simons K, Manski-Nankervis JA, Lumsden NG, Fernando S, de Courten MP, Cox N, Hamblin PS, Janus ED, Nelson CL. Chronic disease IMPACT (chronic disease early detection and improved management in primary care project): An Australian stepped wedge cluster randomised trial. Digit Health 2023; 9:20552076231194948. [PMID: 37588155 PMCID: PMC10426307 DOI: 10.1177/20552076231194948] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 07/28/2023] [Indexed: 08/18/2023] Open
Abstract
Background Interrelated chronic vascular diseases (chronic kidney disease (CKD), type 2 diabetes (T2D) and cardiovascular disease (CVD)) are common with high morbidity and mortality. This study aimed to assess if an electronic-technology-based quality improvement intervention in primary care could improve detection and management of people with and at risk of these diseases. Methods Stepped-wedge trial with practices randomised to commence intervention in one of five 16-week periods. Intervention included (1) electronic-technology tool extracting data from general practice electronic medical records and generating graphs and lists for audit; (2) education regarding chronic disease and the electronic-technology tool; (3) assistance with quality improvement audit plan development, benchmarking, monitoring and support. De-identified data analysis using R 3.5.1 conducted using Bayesian generalised linear mixed model with practice and time-specific random intercepts. Results At baseline, eight included practices had 37,946 active patients (attending practice ≥3 times within 2 years) aged ≥18 years. Intervention was associated with increased OR (95% CI) for: kidney health checks (estimated glomerular filtration rate, urine albumin:creatinine ratio (uACR) and blood pressure) in those at risk 1.34 (1.26-1.42); coded diagnosis of CKD 1.18 (1.09-1.27); T2D diagnostic testing (fasting glucose or HbA1c) in those at risk 1.15 (1.08-1.23); uACR in patients with T2D 1.78 (1.56-2.05). Documented eye checks within recommended frequency in patients with T2D decreased 0.85 (0.77-0.96). There were no significant changes in other assessed variables. Conclusions This electronic-technology-based intervention in primary care has potential to help translate guidelines into practice but requires further refining to achieve widespread improvements across the interrelated chronic vascular diseases.
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Affiliation(s)
- Julia L Jones
- Nephrology, Western Health, Melbourne, Australia
- Western Health Chronic Disease Alliance, Melbourne, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Koen Simons
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
- Office for Research, Western Health, Melbourne, Australia
| | | | - Natalie G Lumsden
- Nephrology, Western Health, Melbourne, Australia
- Western Health Chronic Disease Alliance, Melbourne, Australia
- Department of General Practice, The University of Melbourne, Melbourne, Australia
| | | | - Maximilian P de Courten
- Mitchell Institute for Education and Health Policy, Melbourne, Australia
- Centre for Chronic Disease, Victoria University, Melbourne, Australia
| | - Nicholas Cox
- Western Health Chronic Disease Alliance, Melbourne, Australia
- Centre for Chronic Disease, Victoria University, Melbourne, Australia
- Cardiology, Western Health, Melbourne, Australia
| | - Peter Shane Hamblin
- Western Health Chronic Disease Alliance, Melbourne, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Australia
- Endocrinology and Diabetes, Western Health, Melbourne, Australia
| | - Edward D Janus
- Western Health Chronic Disease Alliance, Melbourne, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Australia
- Medicine, Western Health, Melbourne, Australia
| | - Craig L Nelson
- Nephrology, Western Health, Melbourne, Australia
- Western Health Chronic Disease Alliance, Melbourne, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Australia
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Lightfoot CJ, Wilkinson TJ, Yates T, Davies MJ, Smith AC. 'Self-Management Intervention through Lifestyle Education for Kidney health' (the SMILE-K study): protocol for a single-blind longitudinal randomised controlled trial with nested pilot study. BMJ Open 2022; 12:e064916. [PMID: 36385018 PMCID: PMC9670928 DOI: 10.1136/bmjopen-2022-064916] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 10/17/2022] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Many people living with chronic kidney disease (CKD) are expected to self-manage their condition. Patient activation is the term given to describe the knowledge, skills and confidence a person has in managing their own health and is closely related to the engagement in preventive health behaviours. Self-management interventions have the potential to improve remote disease management and health outcomes. We are testing an evidence-based and theory-based digital self-management structured 10-week programme developed for peoples with CKD called 'My Kidneys & Me'. The primary aim of the study (Self-Management Intervention through Lifestyle Education for Kidney health (SMILE-K)) is to assess the effect on patient activation levels. METHODS AND ANALYSIS A single-blind randomised controlled trial (RCT) with a nested pilot study will assess the feasibility of the intervention and study design before continuation to a full RCT. Individuals aged 18 years or older, with established CKD stage 3-4 (eGFR of 15-59 mL/min/1.73 m2) will be recruited through both primary and secondary care pathways. Participants will be randomised into two groups: intervention group (receive My Kidneys & Me in addition to usual care) and control group (usual care). The primary outcome of the nested pilot study is feasibility and the primary outcome of the full RCT is the Patient Activation Measu (PAM-13). The full RCT will assess the effect of the programme on online self-reported outcomes which will be assessed at baseline, after 10 weeks, and then after 20 weeks in both groups. A total sample size of N=432 participants are required based on a 2:1 randomisation. A substudy will measure physiological changes (eg, muscle mass, physical function) and patient experience (qualitative semi-structured interviews). ETHICS AND DISSEMINATION This study was fully approved by the Research Ethics Committee-Leicester South on the 19 November 2020 (reference: 17/EM/0357). All participants are required to provide informed consent obtained online. The results are expected to be published in scientific journals and presented at clinical research conferences. This is protocol version 1.0 dated 27 January 2021. TRIAL REGISTRATION NUMBER ISRCTN18314195.
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Affiliation(s)
- Courtney J Lightfoot
- Department of Health Sciences, University of Leicester, Leicester, UK
- Leicester NIHR Biomedical Research Centre, Leicester General Hospital, Leicester, UK
| | - Thomas J Wilkinson
- NIHR Applied Research Collaboration East Midlands, Leicester Diabetes Centre, Leicester, UK
| | - Thomas Yates
- Leicester NIHR Biomedical Research Centre, Leicester General Hospital, Leicester, UK
- Diabetes Reseach Centre, Leicester General Hospital, Leicester, UK
| | - Melanie J Davies
- Leicester NIHR Biomedical Research Centre, Leicester General Hospital, Leicester, UK
- Diabetes Reseach Centre, Leicester General Hospital, Leicester, UK
| | - Alice C Smith
- Department of Health Sciences, University of Leicester, Leicester, UK
- Leicester NIHR Biomedical Research Centre, Leicester General Hospital, Leicester, UK
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11
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Lightfoot CJ, Wilkinson TJ, Hadjiconstantinou M, Graham-Brown M, Barratt J, Brough C, Burton JO, Hainsworth J, Johnson V, Martinez M, Nixon AC, Pursey V, Schreder S, Vadaszy N, Wilde L, Willingham F, Young HML, Yates T, Davies MJ, Smith AC. The Codevelopment of "My Kidneys & Me": A Digital Self-management Program for People With Chronic Kidney Disease. J Med Internet Res 2022; 24:e39657. [PMID: 36374538 PMCID: PMC9706383 DOI: 10.2196/39657] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/05/2022] [Accepted: 08/11/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Health care self-management is important for people living with nondialysis chronic kidney disease (CKD). However, the few available resources are of variable quality. OBJECTIVE This work describes the systematic codevelopment of "My Kidneys & Me" (MK&M), a theory-driven and evidence-based digital self-management resource for people with nondialysis CKD, guided by an established process used for the successful development of the diabetes education program MyDESMOND (Diabetes Education and Self-Management for Ongoing and Newly Diagnosed, DESMOND). METHODS A multidisciplinary steering group comprising kidney health care professionals and researchers and specialists in the development of complex interventions and digital health provided expertise in the clinical and psychosocial aspects of CKD, self-management, digital health, and behavior change. A patient and public involvement group helped identify the needs and priorities of MK&M and co-design the resource. MK&M was developed in 2 sequential phases. Phase 1 involved the codevelopment process of the MK&M resource (content and materials), using Intervention Mapping (IM) as a framework. The first 4 IM steps guided the development process: needs assessment was conducted to describe the context of the intervention; intervention outcomes, performance objectives, and behavioral determinants were identified; theory- and evidence-based change methods and practical strategies to deliver change methods were selected; and program components were developed and refined. Phase 2 involved the adoption and adaptation of the existing MyDESMOND digital platform to suit the MK&M resource. RESULTS The needs assessment identified that individuals with CKD have multiple differing needs and that delivering a self-management program digitally would enable accessible, tailored, and interactive information and support. The intended outcomes of MK&M were to improve and maintain effective self-management behaviors, including physical activity and lifestyle, improve knowledge, promote self-care skills, increase self-efficacy, and enhance well-being. This was achieved through the provision of content and materials designed to increase CKD knowledge and patient activation, reduce health risks, manage symptoms, and improve physical function. Theories and behavior change techniques selected include Self-Management Framework, Capability, Opportunity, Motivation Behavior model components of Behaviour Change Wheel and taxonomy of behavior change techniques, Health Action Process Approach Model, Common Sense Model, and Social Cognitive Theory. The program components developed comprised educational and behavior change sessions, health trackers (eg, monitoring blood pressure, symptoms, and exercise), goal-setting features, and forums for social support. The MyDESMOND digital platform represented an ideal existing platform to host MK&M; thus, the MyDESMOND interface and features were adopted and adapted for MK&M. CONCLUSIONS Applying the IM framework enabled the systematic application of theory, empirical evidence, and practical perspectives in the codevelopment of MK&M content and materials. Adopting and adapting a preexisting platform provided a cost- and time-efficient approach for developing our digital intervention. In the next stage of work, the efficacy of MK&M in increasing patient activation will be tested in a randomized controlled trial.
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Affiliation(s)
- Courtney J Lightfoot
- Leicester Kidney Lifestyle Team, Department of Health Sciences, University of Leicester, Leicester, United Kingdom
- Leicester Biomedical Research Centre, Leicester, United Kingdom
| | - Thomas J Wilkinson
- Leicester Kidney Lifestyle Team, Department of Health Sciences, University of Leicester, Leicester, United Kingdom
- National Institute for Health Research Applied Research Collaboration East Midlands, Leicester Diabetes Centre, Leicester, United Kingdom
| | | | - Matthew Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- Department of Renal Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- Department of Renal Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Christopher Brough
- Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - James O Burton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- Department of Renal Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, United Kingdom
| | - Jenny Hainsworth
- Department of Medical Psychology, Leicestershire Partnership NHS Trust, Leicester, United Kingdom
- University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Vicki Johnson
- Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Maria Martinez
- Renal and Transplant Unit, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Andrew C Nixon
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
- Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
| | - Victoria Pursey
- Department of Renal Medicine, York Teaching Hospital NHS Foundation Trust, York, United Kingdom
| | - Sally Schreder
- Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Noemi Vadaszy
- Leicester Kidney Lifestyle Team, Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Lucina Wilde
- Leicester Kidney Lifestyle Team, Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Fiona Willingham
- Nutrition and Dietetics Team, School of Sport and Health Sciences, University of Central Lancashire, Preston, United Kingdom
- Nutrition and Dietetic Department, East Lancashire Hospitals NHS Trust, Blackburn, United Kingdom
| | - Hannah M L Young
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom
- Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Thomas Yates
- Leicester Biomedical Research Centre, Leicester, United Kingdom
- Diabetes Research Centre, College of Life Sciences, University of Leicester, Leicester, United Kingdom
| | - Melanie J Davies
- Leicester Biomedical Research Centre, Leicester, United Kingdom
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom
| | - Alice C Smith
- Leicester Kidney Lifestyle Team, Department of Health Sciences, University of Leicester, Leicester, United Kingdom
- Leicester Biomedical Research Centre, Leicester, United Kingdom
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12
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Cleary F, Kim L, Prieto-Merino D, Wheeler D, Steenkamp R, Fluck R, Adlam D, Denaxas S, Griffith K, Loud F, Hull S, Caplin B, Nitsch D. Association between practice coding of chronic kidney disease (CKD) in primary care and subsequent hospitalisations and death: a cohort analysis using national audit data. BMJ Open 2022; 12:e064513. [PMID: 36220323 PMCID: PMC9558803 DOI: 10.1136/bmjopen-2022-064513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To examine the association between practice percentage coding of chronic kidney disease (CKD) in primary care with risk of subsequent hospitalisations and death. DESIGN Retrospective cohort study using linked electronic healthcare records. SETTING 637 general practitioner (GP) practices in England. PARTICIPANTS 167 208 patients with CKD stages 3-5 identified by 2 measures of estimated glomerular filtration rate <60 mL/min/1.73 m2, separated by at least 90 days, excluding those with coded initiation of renal replacement therapy. MAIN OUTCOME MEASURES Hospitalisations with cardiovascular (CV) events, heart failure (HF), acute kidney injury (AKI) and all-cause mortality RESULTS: Participants were followed for (median) 3.8 years for hospital outcomes and 4.3 years for deaths. Rates of hospitalisations with CV events and HF were lower in practices with higher percentage CKD coding. Trends of a small reduction in AKI but no substantial change in rate of deaths were also observed as CKD coding increased. Compared with patients in the median performing practice (74% coded), patients in practices coding 55% of CKD cases had a higher rate of CV hospitalisations (HR 1.061 (95% CI 1.015 to 1.109)) and HF hospitalisations (HR 1.097 (95% CI 1.013 to 1.187)) and patients in practices coding 88% of CKD cases had a reduced rate of CV hospitalisations (HR 0.957 (95% CI 0.920 to 0.996)) and HF hospitalisations (HR 0.918 (95% CI 0.855 to 0.985)). We estimate that 9.0% of CV hospitalisations and 16.0% of HF hospitalisations could be prevented by improving practice CKD coding from 55% to 88%. Prescription of antihypertensives was the most dominant predictor of a reduction in hospitalisation rates for patients with CKD, followed by albuminuria testing and use of statins. CONCLUSIONS Higher levels of CKD coding by GP practices were associated with lower rates of CV and HF events, which may be driven by increased use of antihypertensives and regular albuminuria testing, although residual confounding cannot be ruled out.
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Affiliation(s)
- Faye Cleary
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Lois Kim
- Cardiovascular Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - David Prieto-Merino
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - David Wheeler
- Department of Renal Medicine, University College London, London, UK
| | | | - Richard Fluck
- Department of Renal Medicine, Royal Derby Hospital, Derby, UK
| | - David Adlam
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Spiros Denaxas
- Institute of Health Informatics, University College London, London, UK
- British Heart Foundation Data Science Centre, London, UK
| | | | - Fiona Loud
- Director of Policy, Kidney Care UK, Alton, UK
| | - Sally Hull
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Ben Caplin
- Department of Renal Medicine, University College London, London, UK
| | - Dorothea Nitsch
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
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13
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Lee SI, Cooper J, Fenton A, Subramanian A, Taverner T, Gokhale KM, Phillips K, Patel M, Harper L, Thomas GN, Nirantharakumar K. Decreased renal function is associated with incident dementia: An IMRD-THIN retrospective cohort study in the UK. Alzheimers Dement 2022; 18:1943-1956. [PMID: 34978143 DOI: 10.1002/alz.12539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 08/26/2021] [Accepted: 10/25/2021] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Decreased renal function is a potential risk factor for dementia. METHODS This retrospective cohort study of 2.8 million adults aged ≥50 years used the IMRD-THIN database, representative of UK primary care, from January 1, 1995 to February 24, 2020. The associations between estimated glomerular filtration rate (eGFR) and urine albumin creatinine ratio (ACR) with incident all-cause dementia were analyzed using Cox regression. RESULTS In the eGFR cohort (n = 2,797,384), worsening renal dysfunction was associated with increased hazard of all-cause dementia, with greatest hazard at eGFR 15-30 ml/min/1.73min2 (hazard ratio [HR] 1.26, 95% confidence interval [CI] 1.19-1.33). In the ACR cohort (n = 641,912), the hazard of dementia increased from ACR 3-30 mg/mmol (HR 1.13, 95% CI 1.10-1.15) to ACR > 30 mg/mmol (HR 1.25, 95% CI 1.18-1.33). DISCUSSION Worsening eGFR and albuminuria have graded associations with the risk of dementia, which may have significant implications for the care of patients with kidney disease.
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Affiliation(s)
- Siang Ing Lee
- Institute of Applied Health Sciences, University of Birmingham, Birmingham, UK
| | - Jennifer Cooper
- Institute of Applied Health Sciences, University of Birmingham, Birmingham, UK
| | - Anthony Fenton
- Institute of Applied Health Sciences, University of Birmingham, Birmingham, UK
| | | | - Tom Taverner
- Institute of Applied Health Sciences, University of Birmingham, Birmingham, UK
| | - Krishna M Gokhale
- Institute of Applied Health Sciences, University of Birmingham, Birmingham, UK
| | - Katherine Phillips
- Institute of Applied Health Sciences, University of Birmingham, Birmingham, UK
| | - Mitesh Patel
- Institute of Applied Health Sciences, University of Birmingham, Birmingham, UK
| | - Lorraine Harper
- Institute of Clinical Sciences, Centre for Translational Inflammation Research, University of Birmingham Research Laboratories, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - G Neil Thomas
- Institute of Applied Health Sciences, University of Birmingham, Birmingham, UK
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14
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Swartling O, Yang Y, Clase CM, Fu EL, Hecking M, Hödlmoser S, Trolle-Lagerros Y, Evans M, Carrero JJ. Sex Differences in the Recognition, Monitoring, and Management of CKD in Health Care: An Observational Cohort Study. J Am Soc Nephrol 2022; 33:1903-1914. [PMID: 35906075 PMCID: PMC9528319 DOI: 10.1681/asn.2022030373] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 06/09/2022] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Reported sex differences in the etiology, population prevalence, progression rates, and health outcomes of people with CKD may be explained by differences in health care. METHODS We evaluated sex as the variable of interest in a health care-based study of adults (n=227,847) with at least one outpatient eGFR<60 ml/min per 1.73 m2 measurement denoting probable CKD in Stockholm from 2009 to 2017. We calculated the odds ratios for diagnosis of CKD and provision of RASi and statins at inclusion, and hazard ratios for CKD diagnosis, visiting a nephrologist, or monitoring creatinine and albuminuria during follow-up. RESULTS We identified 227,847 subjects, of whom 126,289 were women (55%). At inclusion, women had lower odds of having received a diagnostic code for CKD and were less likely to have received RASi and statins, despite having guideline-recommended indications. In time-to-event analyses, women were less likely to have received a CKD diagnosis (HR, 0.43; 95% CI, 0.42 to 0.45) and visited a nephrologist (HR, 0.46; 95% CI, 0.43 to 0.48) regardless of disease severity, presence of albuminuria, or criteria for referral. Women were also less likely to undergo monitoring of creatinine or albuminuria, including those with diabetes or hypertension. These differences remained after adjustment for comorbidities, albuminuria, and highest educational achievement, and among subjects with confirmed CKD at retesting. Although in absolute terms all nephrology-care indicators gradually improved over time, the observed sex gap persisted. CONCLUSIONS There were profound sex differences in the detection, recognition, monitoring, referrals, and management of CKD. The disparity was also observed in people at high risk and among those who had guideline-recommended indications. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/JASN/2022_10_11_JASN2022030373.mp3.
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Affiliation(s)
- Oskar Swartling
- Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden
| | - Yuanhang Yang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Catherine M. Clase
- Departments of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Edouard L. Fu
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Manfred Hecking
- Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Sebastian Hödlmoser
- Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Department of Epidemiology, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Ylva Trolle-Lagerros
- Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden
- Center for Obesity, Academic Specialist Center, Stockholm Health Services, Stockholm, Sweden
| | - Marie Evans
- Department of Clinical Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Juan J. Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Division of Nephrology, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
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15
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Barbagelata L, Masson W, Rossi E, Lee M, Lagoria J, Vilas M, Pizarro R, Rosa Diez G. Cardiovascular Risk Stratification and Appropriate Use of Statins in Patients with Chronic Kidney Disease According to Different Strategies. High Blood Press Cardiovasc Prev 2022; 29:435-443. [PMID: 35751783 DOI: 10.1007/s40292-022-00531-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 06/12/2022] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION Different strategies were proposed to stratify cardiovascular risk and assess the appropriate use of statins in patients with chronic kidney disease (CKD). AIM (1) To apply two strategies on the management of lipids in patients with CKD, analyzing what proportion of patients received lipid-lowering treatment and how many patients without statin therapy would be candidates for receiving them; (2) to identify how many patients achieve the lipid goals. METHODS A cross-sectional study was performed. Patients aged between 18 to 70 years and CKD with an estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73 m2 (without hemodialysis) were included. The indications for statin therapy according to 2019 ESC/EAS and 2013 KDIGO guidelines were analyzed as well as the achievement of LDL-C goals. RESULTS A total of 300 patients were included. According to ESC/EAS guidelines, 62.3 and 37.7% of the population was classified at high or very high cardiovascular risk. In total, 52% of patients received statins. Applying the 2013 KDIGO and the 2019 ESC/EAS guidelines, 92.4 and 95.8% of the population without lipid-lowering treatment were eligible for statin therapy, respectively. Globally, only 9.1 and 10.6% of the patients with high or very high risk achieved the suggested lipid goals. CONCLUSION A large proportion of patients with CKD showed considerable cardiovascular risk and were eligible for statin therapy according to the two strategies evaluated. However, observed statin use was deficient and current lipid goals were not achieved in most cases.
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Affiliation(s)
- Leandro Barbagelata
- Cardiology Department, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB, Buenos Aires, Argentina.
| | - Walter Masson
- Cardiology Department, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB, Buenos Aires, Argentina
| | - Emiliano Rossi
- Cardiology Department, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB, Buenos Aires, Argentina
| | - Martin Lee
- Cardiology Department, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB, Buenos Aires, Argentina
| | - Juan Lagoria
- Cardiology Department, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB, Buenos Aires, Argentina
| | - Manuel Vilas
- Nefrology Department, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB, Buenos Aires, Argentina
| | - Rodolfo Pizarro
- Cardiology Department, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB, Buenos Aires, Argentina
| | - Guillermo Rosa Diez
- Nefrology Department, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABB, Buenos Aires, Argentina
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16
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Hecking M, Hödlmoser S, Ahmed SB, Carrero JJ. The Other Way Around: Living With Chronic Kidney Disease From the Perspective of Men. Semin Nephrol 2022; 42:122-128. [PMID: 35718360 DOI: 10.1016/j.semnephrol.2022.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
A wealth of evidence has suggested sex (biological) and gender (sociocultural) differences in the prevalence, progression, and outcomes of persons with chronic kidney disease. Much of this evidence tends to emphasize differences in which women are disadvantaged, and less attention is paid to findings in which women are better off or similar to men. However, gender medicine recognizes that men and women have different disease determinants, presentation, and attitudes, and it pertains to both sexes. In this review, we revisit chronic kidney disease through the perspective of men, and illustrate a population segment at need of stringent preventative and management strategies.
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Affiliation(s)
- Manfred Hecking
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Sebastian Hödlmoser
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Sofia B Ahmed
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Centre for Gender Medicine, Karolinska Institutet, Stockholm, Sweden.
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17
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Major RW, Shepherd D, Medcalf JF, Xu G, Gray LJ, Brunskill NJ. Comorbidities and outcomes in South Asian individuals with chronic kidney disease: an observational primary care cohort. Nephrol Dial Transplant 2021; 37:108-114. [PMID: 33439998 DOI: 10.1093/ndt/gfaa291] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND South Asian (SA) individuals are more likely to develop end-stage renal disease (ESRD), but how chronic kidney disease (CKD) differs in relation to demographics, comorbidities and outcomes has not been studied. We aimed to study differences in SA individuals with CKD compared with White individuals. METHODS This was an observational CKD cohort comparing SA with White individuals. Inclusion criteria were ≥18 years of age and two or more Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) eGFRs <60 mL/min/1.73 m2 >3 months apart. Individuals with ESRD at baseline were excluded. Baseline characteristics, including eGFR formulae [CKD-EPI and CKD-EPI-Pakistan (CKD-EPI-PK)], were compared. Analysis using competing risk regression for cardiovascular (CV) and ESRD events and Cox proportional hazard model for mortality was performed. RESULTS From an adult population of 277 248 individuals, 17 248 individuals had CKD, of whom 1990 (11.5%) were of SA ethnicity. Age-adjusted prevalence of CKD was similar between ethnicities. SA individuals were more likely to be male, younger and socioeconomically deprived, and to have diabetes mellitus, CV disease and advanced CKD. Mean CKD-EPI-PK eGFR was 6.5 mL/min/1.73 m2 lower (41.1 versus 47.6, 95% confidence interval for difference 6.47-6.56) than for CKD-EPI. During 5 years of follow-up, 5109 (29.6%) individuals died, 2072 (12.0%) had a CV and 156 (0.90%) an ESRD event. Risk for SA individuals was higher for ESRD, similar to CV events and lower for mortality. Each 1 mL/min/1.73 m2 decrease in CKD-EPI-PK was associated with a 13.1% increased ESRD risk (adjusted subdistribution hazard ratio 0.869, 95% confidence interval 0.841-0.898). CONCLUSIONS SA individuals with CKD were younger and had more advanced disease than White individuals. Risk of ESRD was higher and CKD-EPI-PK was associated with ESRD risk in SA individuals. Specific CKD interventions, including the use of CKD-EPI-PK, should be considered in SA populations.
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Affiliation(s)
- Rupert W Major
- John Walls Renal Unit, University Hospitals of Leicester, Leicester General Hospital, Leicester, UK.,Department of Health Sciences, University of Leicester, Leicester, UK
| | - David Shepherd
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - James F Medcalf
- John Walls Renal Unit, University Hospitals of Leicester, Leicester General Hospital, Leicester, UK.,Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Gang Xu
- John Walls Renal Unit, University Hospitals of Leicester, Leicester General Hospital, Leicester, UK
| | - Laura J Gray
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Nigel J Brunskill
- John Walls Renal Unit, University Hospitals of Leicester, Leicester General Hospital, Leicester, UK.,Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
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Hypertension and cardiovascular risk factor management in a multi-ethnic cohort of adults with CKD: a cross sectional study in general practice. J Nephrol 2021; 35:901-910. [PMID: 34782969 PMCID: PMC8995266 DOI: 10.1007/s40620-021-01149-0] [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: 05/17/2021] [Accepted: 08/22/2021] [Indexed: 12/01/2022]
Abstract
Background Hypertension, especially if poorly controlled, is a key determinant of chronic kidney disease (CKD) development and progression to end stage renal disease (ESRD). Aim To assess hypertension and risk factor management, and determinants of systolic blood pressure control in individuals with CKD and hypertension. Design and setting Cross-sectional survey using primary care electronic health records from 47/49 general practice clinics in South London. Methods Known effective interventions, management of hypertension and cardiovascular disease (CVD) risk in patients with CKD Stages 3–5 were investigated. Multivariable logistic regression analysis examined the association of demographic factors, comorbidities, deprivation, and CKD coding, with systolic blood pressure control status as outcome. Individuals with diabetes were excluded. Results Adults with CKD Stages 3–5 and hypertension represented 4131/286,162 (1.4%) of the total population; 1984 (48%) of these individuals had undiagnosed CKD without a recorded CKD clinical code. Hypertension was undiagnosed in 25% of the total Lambeth population, and in patients with CKD without diagnosed hypertension, 23.0% had systolic blood pressure > 140 mmHg compared with 39.8% hypertensives, p < 0.001. Multivariable logistic regression revealed that factors associated with improved systolic blood pressure control in CKD included diastolic blood pressure control, serious mental illness, history of cardiovascular co-morbidities, CKD diagnostic coding, and age < 60 years. African ethnicity and obesity were associated with poorer systolic blood pressure control. Conclusion We found both underdiagnosed CKD and underdiagnosed hypertension in patients with CKD. The poor systolic blood pressure control in older age groups ≥ 60 years and in Black African or obese individuals is clinically important as these groups are at increased risk of mortality for cardiovascular diseases. Graphic abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s40620-021-01149-0.
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Impact of Using Risk-Based Stratification on Referral of Patients With Chronic Kidney Disease From Primary Care to Specialist Care in the United Kingdom. Kidney Int Rep 2021; 6:2189-2199. [PMID: 34386668 PMCID: PMC8343777 DOI: 10.1016/j.ekir.2021.05.031] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 05/18/2021] [Accepted: 05/24/2021] [Indexed: 11/20/2022] Open
Abstract
Introduction The externally validated Kidney Failure Risk Equation (KFRE) for predicting risk of end-stage renal disease (ESRD) has been developed, but its potential impact in a population on referrals for patients with chronic kidney disease (CKD) from primary to specialty nephrology care is not known. Methods A cross-sectional population-based study of individuals in United Kingdom primary care registered in The Health Improvement Network database was conducted. National Institute of Health and Care Excellence (NICE) 2014 CKD guidelines versus the 4-variable KFRE set at a >3% risk of ESRD at 5 years were applied to patients identified with CKD stage 3-5 between January 1, 2016, and March 31, 2017. Results In all, 39,476 (36.6%) of 107,962 adults with CKD stage 3-5 had a urine albumin:creatinine ratio (ACR) available and entered into the primary analysis. Of that, 7566 (19.2%) patients fulfilled NICE criteria for referral, 2386 (31.5%) of whom had a ≤3% 5-year risk of ESRD. Also 8663 (21.9%) patients had a >3% 5-year risk of ESRD, 3483 (40.2%) of whom did not fulfill NICE criteria; this represents 8.8% of the primary population. By using the KFRE threshold rather than NICE criteria for referral, 5869 patients (14.9% of the primary analysis population) would have been reallocated between primary and specialist care. Imputational analysis was used for missing ACR measurements and showed similar results. Conclusions A risk-based referral approach would lead to a substantial reallocation of patients between primary care and specialist nephrology care with only a small increase in numbers eligible, ensuring those at higher risk of progression are identified.
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Ould Setti M, Voutilainen A, Tuomainen TP. Renal hyperfiltration, fatty liver index, and the hazards of all-cause and cardiovascular mortality in Finnish men. Epidemiol Health 2020; 43:e2021001. [PMID: 33445827 PMCID: PMC7952838 DOI: 10.4178/epih.e2021001] [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] [Received: 08/27/2020] [Accepted: 12/18/2020] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Renal hyperfiltration (RHF) and fatty liver are separately associated with adverse health outcomes. In this study, we investigated the mortality hazard of coexisting RHF and fatty liver. METHODS Middle-aged men from the Kuopio Ischaemic Disease Risk Factor Study (n=1,552) were followed up for a median of 29 years. Associations among RHF, fatty liver index (FLI) score, age, body mass index, smoking status, alcohol consumption, and hypertension status were assessed using logistic regression. Cox proportional hazards models were used to determine the hazard ratios (HRs) for all-cause and cardiovascular disease (CVD) mortality with respect to RHF and fatty liver. RESULTS Of the men, 5% had RHF (n=73), whereas a majority had fatty liver (n=848). RHF was associated specifically with smoking, and fatty liver was associated specifically with overweight. The all-cause mortality hazard was highest (HR, 1.96; 95% confidence interval [CI], 1.27 to 3.01) among men with RHF and fatty liver (n=33). Among men with RHF but normal FLI (n=40), the HR of all-cause mortality was 1.67 (95% CI, 1.15 to 2.42). Among men with fatty liver but a normal estimated glomerular filtration rate (n=527), the HR of all-cause mortality was 1.35 (95% CI, 1.09 to 1.66). CVD mortality hazard was associated with RHF, but not fatty liver. We detected no interaction effect between RHF and fatty liver for all-cause (synergy index, 0.74; 95% CI, 0.21 to 2.67) or CVD (synergy index, 0.94; 95% CI, 0.34 to 2.60) mortality. CONCLUSIONS RHF and fatty liver are independently associated with all-cause and CVD mortality
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Affiliation(s)
- Mounir Ould Setti
- Department of Public Health, University of Eastern Finland, Kuopio, Finland
| | - Ari Voutilainen
- Department of Public Health, University of Eastern Finland, Kuopio, Finland
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Uncoded chronic kidney disease in primary care: a cross-sectional study of inequalities and cardiovascular disease risk management. Br J Gen Pract 2020; 70:e785-e792. [PMID: 33077509 DOI: 10.3399/bjgp20x713105] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 03/02/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Uncoded chronic kidney disease (CKD) is associated with poorer quality of care. AIM To ascertain the proportion and determinants of CKD, which have not been formally recorded (Read coded), and identify differences in management and quality-of-care measures for patients with coded and uncoded CKD. DESIGN AND SETTING Cross-sectional survey undertaken in an ethnically diverse adult population using primary care electronic health records (EHRs) from GP clinics in Lambeth, South London, UK. METHOD Multivariable logistic regression analysis examined the association of demographic factors, selected comorbidities, deprivation, and cardiovascular disease risk management in CKD, with coding status as outcome. RESULTS In total, the survey involved 286 162 adults, of whom 9325 (3.3%) were identified with CKD stage 3-5 (assigned as CKD based on estimated glomerular filtration rate [eGFR] values). Of those identified with CKD, 4239 (45.5%) were Read coded, and 5086 (54.5%) were uncoded. Of those identified with CKD stage 3-5, individuals aged ≥50 years were more likely to be coded for CKD, compared with those aged <50 years. Lower levels of coding were independently associated with deprivation and black Caribbean, black African, South Asian, and non-stated ethnicities, compared with white ethnicity. Prescribed statin and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker medications were associated with increased odds of coded CKD. CONCLUSION This study found that >50% of CKD was uncoded and, for those patients, quality of care was lower compared with those with coded CKD. Future research and practices should focus on areas of greater deprivation and targeted initiatives for those aged <50 years and of black African, black Caribbean, South Asian, or non-stated ethnic groups. Possible areas for improvement include diagnostic coding support, automated CKD recording, and clinical decision support (based on adjusted eGFR results) in the GP clinical records.
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Sofue T, Nakagawa N, Kanda E, Nagasu H, Matsushita K, Nangaku M, Maruyama S, Wada T, Terada Y, Yamagata K, Narita I, Yanagita M, Sugiyama H, Shigematsu T, Ito T, Tamura K, Isaka Y, Okada H, Tsuruya K, Yokoyama H, Nakashima N, Kataoka H, Ohe K, Okada M, Kashihara N. Prevalences of hyperuricemia and electrolyte abnormalities in patients with chronic kidney disease in Japan: A nationwide, cross-sectional cohort study using data from the Japan Chronic Kidney Disease Database (J-CKD-DB). PLoS One 2020; 15:e0240402. [PMID: 33057377 PMCID: PMC7561156 DOI: 10.1371/journal.pone.0240402] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 09/24/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The Japan Chronic Kidney Disease Database (J-CKD-DB) is a nationwide clinical database of patients with chronic kidney disease (CKD) based on electronic health records. The objective of this study was to assess the prevalences of hyperuricemia and electrolyte abnormalities in Japanese patients with CKD. METHODS In total, 35,508 adult outpatients with estimated glomerular filtration rates of 5-60 ml/min/1.73 m2 in seven university hospitals were included this analysis. The proportions of patients with CKD stages G3b, G4, and G5 were 23.5%, 7.6%, and 3.1%, respectively. RESULTS Logistic regression analysis showed that prevalence of hyperuricemia was associated with CKD stages G3b (adjusted odds ratio [95% confidence interval]: 2.12 [1.90-2.37]), G4 (4.57 [3.92-5.32]), and G5 (2.25 [1.80-2.80]). The respective prevalences of hyponatremia, hypercalcemia, hyperphosphatemia, and narrower difference between serum sodium and chloride concentrations were elevated in patients with CKD stages G3b, G4, and G5, compared with those prevalences in patients with CKD stage G3a. The prevalences of hyperkalemia were 8.3% and 11.6% in patients with CKD stages G4 and G5, respectively. In patients with CKD stage G5, the proportions of patients with optimal ranges of serum uric acid, potassium, corrected calcium, and phosphate were 49.6%, 73.5%, 81.9%, and 56.1%, respectively. CONCLUSIONS We determined the prevalences of hyperuricemia and electrolyte abnormalities in Japanese patients with CKD using data from a nationwide cohort study.
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Affiliation(s)
- Tadashi Sofue
- Division of Nephrology and Dialysis, Department of Cardiorenal and Cerebrovascular Medicine, Kagawa University, Kagawa, Japan
| | - Naoki Nakagawa
- Division of Cardiology, Nephrology, Respiratory and Neurology, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Eiichiro Kanda
- Medical Science, Kawasaki Medical School, Kurashiki, Japan
| | - Hajime Nagasu
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takashi Wada
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Kanazawa, Japan
| | - Yoshio Terada
- Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kochi University, Kochi, Japan
| | - Kunihiro Yamagata
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Motoko Yanagita
- Department of Nephrology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hitoshi Sugiyama
- Department of Human Resource Development of Dialysis Therapy for Kidney Disease, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | | | - Takafumi Ito
- Division of Nephrology, Faculty of Medicine, Shimane University, Izumo, Japan
| | - Kouichi Tamura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yoshitaka Isaka
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hirokazu Okada
- Department of Nephrology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
| | - Kazuhiko Tsuruya
- Department of Integrated Therapy for Chronic Kidney Disease, Kyushu University, Fukuoka, Japan
- Department of Nephrology, Nara Medical University, Kashihara, Japan
| | - Hitoshi Yokoyama
- Department of Nephrology, Kanazawa Medical University School of Medicine, Ishikawa, Japan
| | - Naoki Nakashima
- Medical Information Center, Kyushu University Hospital, Fukuoka, Japan
| | - Hiromi Kataoka
- Faculty of Health Science and Technology, Kawasaki University of Medical Welfare, Kurashiki, Japan
| | - Kazuhiko Ohe
- Department of Healthcare Information Management, The University of Tokyo Hospital, Tokyo, Japan
| | - Mihoko Okada
- Institute of Health Data Infrastructure for All, Tokyo, Japan
| | - Naoki Kashihara
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
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Sofue T, Nakagawa N, Kanda E, Nagasu H, Matsushita K, Nangaku M, Maruyama S, Wada T, Terada Y, Yamagata K, Narita I, Yanagita M, Sugiyama H, Shigematsu T, Ito T, Tamura K, Isaka Y, Okada H, Tsuruya K, Yokoyama H, Nakashima N, Kataoka H, Ohe K, Okada M, Kashihara N. Prevalence of anemia in patients with chronic kidney disease in Japan: A nationwide, cross-sectional cohort study using data from the Japan Chronic Kidney Disease Database (J-CKD-DB). PLoS One 2020; 15:e0236132. [PMID: 32687544 PMCID: PMC7371174 DOI: 10.1371/journal.pone.0236132] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 06/29/2020] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The Japan Chronic Kidney Disease Database (J-CKD-DB) is a nationwide clinical database of patients with chronic kidney disease (CKD) based on electronic health records. The objective of this study was to assess the prevalence of anemia and the utilization rate of erythropoiesis-stimulating agents (ESAs) in Japanese patients with CKD. METHODS In total, 31,082 adult outpatients with estimated glomerular filtration rates of 5-60 ml/min/1.73 m2 in seven university hospitals were included this analysis. The proportions of patients with CKD stages G3b, G4, and G5 were 23.5%, 7.6%, and 3.1%, respectively. RESULTS The mean (standard deviation) hemoglobin level of male patients was 13.6 (1.9) g/dl, which was significantly higher than the mean hemoglobin level of female patients (12.4 (1.6) g/dl). The mean (standard deviation) hemoglobin levels were 11.4 (2.1) g/dl in patients with CKD stage G4 and 11.2 (1.8) g/dl in patients with CKD stage G5. The prevalences of anemia were 40.1% in patients with CKD stage G4 and 60.3% in patients with CKD stage G5. Logistic regression analysis showed that diagnoses of CKD stage G3b (adjusted odds ratio [95% confidence interval]: 2.32 [2.09-2.58]), G4 (5.50 [4.80-6.31]), and G5 (9.75 [8.13-11.7]) were associated with increased prevalence of anemia. The utilization rates of ESAs were 7.9% in patients with CKD stage G4 and 22.4% in patients with CKD stage G5. CONCLUSIONS We determined the prevalence of anemia and utilization rate of ESAs in Japanese patients with CKD using data from a nationwide cohort study.
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Affiliation(s)
- Tadashi Sofue
- Division of Nephrology and Dialysis, Department of Cardiorenal and Cerebrovascular Medicine, Kagawa University, Kagawa, Japan
- * E-mail:
| | - Naoki Nakagawa
- Division of Cardiology, Nephrology, Respiratory and Neurology, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Eiichiro Kanda
- Medical Science, Kawasaki Medical School, Kurashiki, Japan
| | - Hajime Nagasu
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Shoichi Maruyama
- Division of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takashi Wada
- Division of Nephrology, Department of Nephrology and Laboratory Medicine, Kanazawa University, Kanazawa, Japan
| | - Yoshio Terada
- Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kochi University, Kochi, Japan
| | - Kunihiro Yamagata
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Motoko Yanagita
- Department of Nephrology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hitoshi Sugiyama
- Department of Human Resource Development of Dialysis Therapy for Kidney Disease, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Takashi Shigematsu
- Division of Nephrology, Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Takafumi Ito
- Division of Nephrology, Faculty of Medicine, Shimane University, Izumo, Japan
| | - Kouichi Tamura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yoshitaka Isaka
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hirokazu Okada
- Department of Nephrology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
| | - Kazuhiko Tsuruya
- Department of Integrated Therapy for Chronic Kidney Disease, Kyushu University, Fukuoka, Japan
- Department of Nephrology, Nara Medical University, Kashihara, Japan
| | - Hitoshi Yokoyama
- Department of Nephrology, Kanazawa Medical University School of Medicine, Ishikawa, Japan
| | - Naoki Nakashima
- Department of Advanced Information Technology, Kyushu University, Fukuoka, Japan
| | - Hiromi Kataoka
- Faculty of Health Science and Technology, Kawasaki University of Medical Welfare, Kurashiki, Japan
| | - Kazuhiko Ohe
- Department of Healthcare Information Management, The University of Tokyo Hospital, Tokyo, Japan
| | - Mihoko Okada
- Institute of Health Data Infrastructure for All, Tokyo, Japan
| | - Naoki Kashihara
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
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Pyart R, Lim S, Hussein B, Riley S, Roberts G. Who do we discharge from renal clinic and what does it mean for primary care? Fam Pract 2020; 37:187-193. [PMID: 31603190 DOI: 10.1093/fampra/cmz055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND It is unclear whether discharging patients from renal clinic to primary care is safe. AIM To determine the characteristics, primary care monitoring and renal outcomes of patients discharged from renal clinic. DESIGN AND SETTING A retrospective study of 2236 adults discharged from a tertiary renal clinic between 2013-2018. METHOD Patient demographics, primary renal disease, laboratory results and timeline dates were collected from the renal IT system. Timing of blood tests, renal progression, needing dialysis and patient survival were analysed. Reasons for discharge and cause of disease progression were reviewed in patients developing new estimated glomerular filtration rate <20 ml/min/1.73 m2. RESULTS Patients were older (median age 75; interquartile range 63-84) with non-progressive, seemingly non-proteinuric renal disease. Median time to repeat blood test post-discharge was 75 days with 90% tested within 12 months. Sixty-six percent saw an improvement in kidney function post-discharge and only 13% had a decline of >10 ml/min/1.73 m2. Only 132 patients (6%) developed new advanced chronic kidney disease (estimated glomerular filtration rate < 20 ml/min/1.73 m2) of whom 40% were palliative, 36% had developed acute kidney injury and 23% discharged for failing to attend clinic. One hundred and thirty-four patients (6%) were referred back to nephrology and eight started dialysis of whom six were discharged for failure to attend clinic. CONCLUSION Most discharged patients are low risk of progressive renal disease and need infrequent monitoring. Non-adherent patients discharged for failing to attend appear to be at risk of poor outcomes and new strategies are needed to better support this population.
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Affiliation(s)
- Rhodri Pyart
- Department of Nephrology and Transplantation, University Hospital of Wales, Cardiff, UK
| | - Sheryl Lim
- Department of Nephrology and Transplantation, University Hospital of Wales, Cardiff, UK
| | - Bilal Hussein
- Department of Nephrology and Transplantation, University Hospital of Wales, Cardiff, UK
| | - Steve Riley
- Department of Nephrology and Transplantation, University Hospital of Wales, Cardiff, UK
| | - Gareth Roberts
- Department of Nephrology and Transplantation, University Hospital of Wales, Cardiff, UK
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Affiliation(s)
- Paul Cockwell
- Department of Renal Medicine, Queen Elizabeth Hospital, Birmingham B15 2WG, UK; College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
| | - Lori-Ann Fisher
- University Hospital of the West Indies and University of West Indies, Kingston, Jamaica
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The National CKD Audit: a primary care condition that deserves more attention. Br J Gen Pract 2019; 68:356-357. [PMID: 30049752 DOI: 10.3399/bjgp18x697997] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Using chronic kidney disease trigger tools for safety and learning: a qualitative evaluation in East London primary care. Br J Gen Pract 2019; 69:e715-e723. [PMID: 31455641 DOI: 10.3399/bjgp19x705497] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 05/21/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND An innovative programme to improve identification and management of chronic kidney disease (CKD) in primary care was implemented across three clinical commissioning groups (CCGs) in 2016. This included a falling estimated glomerular filtration rate (eGFR) trigger tool built from data in the electronic health record (EHR). This tool notifies GP practices of falling eGFR values. By alerting clinicians to patients with possible CKD progression the tool invites clinical review, a referral option, and written reflection on management. AIM To identify practitioner perceptions of trigger tool use from interviews, and compare these with reflections on clinical management recorded within the tools. DESIGN AND SETTING A qualitative analysis set in 136 practices across East London during 2016-2018. METHOD Eight semi-structured interviews with GPs and practice staff were recorded, and thematic analysis was undertaken using framework analysis. The reflective comments recorded in the trigger tools of 1921 cases were categorised by age group, referral status, and by the drop in eGFR (>15 or >25 ml/min). RESULTS Three themes emerged from the interviews: getting started, patient safety, and trigger tools for learning. Well-organised practices found the tool was readily embedded into workflow and expressed greater motivation for using it. The tool was seen to support patient safety, and was used for learning about CKD management, both individually and as a practice. Reflective comments from 1921 trigger tools were reviewed. These supported the theme of patient safety. The free-text data, stratified by age, challenged the expectation that younger cases, at higher risk of progressive CKD, would have higher referral rates. CONCLUSION Building electronic trigger tools from the EHR can identify patients with a falling eGFR, prompting review of the eGFR trajectory and management plan. Interview and reflective data illustrated that practice use of the tool supports the patient safety agenda and encourages learning about CKD management.
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Bello AK, Ronksley PE, Tangri N, Kurzawa J, Osman MA, Singer A, Grill AK, Nitsch D, Queenan JA, Wick J, Lindeman C, Soos B, Tuot DS, Shojai S, Brimble KS, Mangin D, Drummond N. Quality of Chronic Kidney Disease Management in Canadian Primary Care. JAMA Netw Open 2019; 2:e1910704. [PMID: 31483474 PMCID: PMC6727682 DOI: 10.1001/jamanetworkopen.2019.10704] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
IMPORTANCE Although patients with chronic kidney disease (CKD) are routinely managed in primary care settings, no nationally representative study has assessed the quality of care received by these patients in Canada. OBJECTIVE To evaluate the current state of CKD management in Canadian primary care practices to identify care gaps to guide development and implementation of national quality improvement initiatives. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study leveraged Canadian Primary Care Sentinel Surveillance Network data from January 1, 2010, to December 31, 2015, to develop a cohort of 46 162 patients with CKD managed in primary care practices. Data analysis was performed from August 8, 2018, to July 31, 2019. MAIN OUTCOMES AND MEASURES The study examined the proportion of patients with CKD who met a set of 12 quality indicators in 6 domains: (1) detection and recognition of CKD, (2) testing and monitoring of kidney function, (3) use of recommended medications, (4) monitoring after initiation of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs), (5) management of blood pressure, and (6) monitoring for glycemic control in those with diabetes and CKD. The study also analyzed associations of divergence from these quality indicators. RESULTS The cohort comprised 46 162 patients (mean [SD] age, 69.2 [14.0] years; 25 855 [56.0%] female) with stage 3 to 5 CKD. Only 4 of 12 quality indicators were met by 75% or more of the study cohort. These indicators were receipt of an outpatient serum creatinine test within 18 months after confirmation of CKD, receipt of blood pressure measurement at any time during follow-up, achieving a target blood pressure of 140/90 mm Hg or lower, and receiving a hemoglobin A1c test for monitoring diabetes during follow-up. Indicators in the domains of detection and recognition of CKD, testing and monitoring of kidney function (specifically, urine albumin to creatinine ratio testing), use of recommended medications, and appropriate monitoring after initiation of treatment with ACEIs or ARBs were not met. Only 6529 patients (18.4%) with CKD received a urine albumin test within 6 months of CKD diagnosis, and 3954 (39.4%) had a second measurement within 6 months of an abnormal baseline urine albumin level. Older age (≥85 years) and CKD stage 5 were significantly associated with not satisfying the criteria for the quality indicators across all domains. Across age categories, younger patients (aged 18-49 years) and older patients (≥75 years) were less likely to be tested for albuminuria (314 of 1689 patients aged 18-49 years [18.5%], 1983 of 11 919 patients aged 75-84 years [61.6%], and 614 of 5237 patients aged ≥85 years [11.7%] received the urine albumin to creatinine ratio test within 6 months of initial estimated glomerular filtration rate <60 mL/min per 1.73 m2; P < .001). Patients aged 18 to 49 years were less commonly prescribed recommended medications (222 of 2881 [7.7%]), whereas patients aged 75 to 84 years were prescribed ACEIs or ARBs most frequently (2328 of 5262 [44.2%]; P < .001). CONCLUSIONS AND RELEVANCE The findings suggest that management of CKD across primary care practices in Canada varies according to quality indicator. This study revealed potential priority areas for quality improvement initiatives in Canadian primary care practices.
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Affiliation(s)
- Aminu K. Bello
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Paul E. Ronksley
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Navdeep Tangri
- Department of Medicine, Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Julia Kurzawa
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Mohamed A. Osman
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Alexander Singer
- Department of Family Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Allan K. Grill
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Dorothea Nitsch
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - John A. Queenan
- Canadian Primary Care Sentinel Surveillance Network, Department of Family Medicine, Queen’s University, Kingston, Ontario, Canada
| | - James Wick
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cliff Lindeman
- Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Boglarka Soos
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Delphine S. Tuot
- Division of Nephrology, University of California, San Francisco
- Kidney Health Research Institute, University of California, San Francisco
| | - Soroush Shojai
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - K. Scott Brimble
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Dee Mangin
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Neil Drummond
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
- Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada
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Schultze A, Graham S, Nordstrom BL, Mehmud F, Ramagopalan SV. Commonly used definitions in real-world studies may underestimate the prevalence of renal disease among nonvalvular atrial fibrillation patients. J Comp Eff Res 2019; 8:961-968. [PMID: 31317772 DOI: 10.2217/cer-2019-0070] [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: 11/21/2022] Open
Abstract
Aim: To describe comorbidities among treated nonvalvular atrial fibrillation (NVAF) patients and assess the impact of using different time ('look back' windows) on the prevalence estimates. Patients & methods: We included all adult nonvalvular atrial fibrillation patients newly initiating treatment in the Clinical Practice Research Datalink. Comorbidities included in the Charlson Comorbidity Index were defined using an all available, 3- and 1-year look back window before the start of treatment. Results: The prevalence of comorbidities was high and increased when using longer look back windows; the largest difference was observed for renal disease (+15.6%). Conclusion: Our findings emphasize the importance of using all available data when characterizing chronic conditions and highlights the high comorbidity burden in this population.
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Affiliation(s)
| | | | | | - Faisal Mehmud
- Centre for Observational Research & Data Sciences, Bristol-Myers Squibb, Uxbridge, UB8 1DH, UK
| | - Sreeram V Ramagopalan
- Centre for Observational Research & Data Sciences, Bristol-Myers Squibb, Uxbridge, UB8 1DH, UK
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Olaitan A, Ashman N, Homer K, Hull S. Predictors of late presentation to renal dialysis: a cohort study of linked primary and secondary care records in East London. BMJ Open 2019; 9:e028431. [PMID: 31230023 PMCID: PMC6596938 DOI: 10.1136/bmjopen-2018-028431] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES The outcomes and experience of care for patients who start renal replacement therapy (RRT) in an unplanned manner are worse than for those who have planned care. The objective of this study was to examine the primary care predictors of unplanned starts to RRT. DESIGN Retrospective cohort study with linked primary care and hospital data. SETTING 128 general practices in East London with a combined population of 1 043 346 people. PARTICIPANTS 999 consecutive patients starting dialysis at Barts Health National Health Service Trust between September 2014 and August 2017. PRIMARY OUTCOME MEASURES Unplanned versus a planned start to dialysis among the cohort of 389 patients with a linked primary care record. An unplanned start to dialysis is defined as receiving nephrology care in the low clearance clinic (or equivalent) for less than 90 days. A planned start is defined as access to pre-dialysis counselling and care for at least 90 days prior to commencing dialysis. RESULTS The adjusted logistic regression analysis showed that the most important modifiable risk factors for unplanned dialysis were the absence of a chronic kidney disease (CKD) code in the general practice (GP) record (OR 8.02, 95% CI 3.65 to 17.63) and the absence of prescribed lipid lowering medication (OR 2.37, 95% CI 1.05 to 5.34). Other contributing factors included male gender and a greater number of long-term conditions. CONCLUSIONS Improving CKD coding in primary care and the additional review and clinical scrutiny associated with this may contribute to a further reduction in unplanned RRT rates.
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Affiliation(s)
| | - Neil Ashman
- Renal Medicine, Barts Health NHS Trust, London, UK
| | - Kate Homer
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Sally Hull
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
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Improving coding and primary care management for patients with chronic kidney disease: an observational controlled study in East London. Br J Gen Pract 2019; 69:e454-e461. [PMID: 31160369 DOI: 10.3399/bjgp19x704105] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 12/21/2018] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND The UK national chronic kidney disease (CKD) audit in primary care shows diagnostic coding in the electronic health record for CKD averages 70%, with wide practice variation. Coding is associated with improvements to risk factor management; CKD cases coded in primary care have lower rates of unplanned hospital admission. AIM To increase diagnostic coding of CKD (stages 3-5) and primary care management, including blood pressure to target and prescription of statins to reduce cardiovascular disease risk. DESIGN AND SETTING Controlled, cross-sectional study in four East London clinical commissioning groups (CCGs). METHOD Interventions to improve coding formed part of a larger system change to the delivery of renal services in both primary and secondary care in East London. Quarterly anonymised data on CKD coding, blood pressure values, and statin prescriptions were extracted from practice computer systems for 1-year pre- and post-initiation of the intervention. RESULTS Three intervention CCGs showed significant coding improvement over a 1 year period following the intervention (regression for post-intervention trend P<0.001). The CCG with highest coding rates increased from 76-90% of CKD cases coded; the lowest coding CCG increased from 52-81%. The comparison CCG showed no change in coding rates. Combined data from all practices in the intervention CCGs showed a significant increase in the proportion of cases with blood pressure achieving target levels (difference in proportion P<0.001) over the 2-year study period. Differences in statin prescribing were not significant. CONCLUSION Clinically important improvements to coding and management of CKD in primary care can be achieved by quality improvement interventions that use shared data to track and monitor change supported by practice-based facilitation. Alignment of clinical and CCG priorities and the provision of clinical targets, financial incentives, and educational resource were additional important elements of the intervention.
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