An observational study of the quality of care for chronic kidney disease: a Buffalo and Albany, New York metropolitan area study

Factors associated with potentially inappropriate prescribing in elderly patients with various degrees of chronic kidney disease

INTRODUCTION

This study aimed to compare the prevalence of potentially inappropriately prescribed drugs in hemodialysis patients and patients with chronic kidney disease who did not require renal replacement therapy, as well as to identify risk factors associated with potentially inappropriate prescribing.

METHODS

The study was designed as a cross-sectional study conducted at the Department of Nephrology, Clinical Center in Nis, Serbia. The patients were divided into two groups: (1) patients on hemodialysis treatment and (2) patients with various degrees of chronic kidney disease without renal replacement therapy. The presence or absence of potentially inappropriate prescribing was determined using the 2015 AGS Beers criteria.

FINDINGS

The study included a total of 218 patients aged 65 years and over. The number of patients with potentially inappropriate prescribed drugs did not differ significantly (chi-square = 0.000, p = 1.000) between patients on hemodialysis (27 of 83, i.e., 32.5%) and patients with various degrees of chronic kidney disease without renal replacement therapy (44 of 135, i.e., 32.6%). Factors associated with potentially inappropriate prescribing in hemodialysis patients were the number of drugs (hazard ratio [HR] = 1.919, 95% confidence interval [CI]: 1.325-2.780) and number of comorbidities (HR = 1.743, 95% CI: 1.109-2.740). The number of drugs (HR = 1.438, 95% CI: 1.191-1.736) was the only independent factor associated with increased risk of potentially inappropriate prescribing in patients without renal replacement therapy.

DISCUSSION

Our study showed that potentially inappropriate prescribing is a relatively frequent phenomenon present in about a third of patients in both study groups. The number of prescribed drugs was the main factor associated with the increased risk of potentially inappropriate prescribing in both groups.

The ICD-9 to ICD-10 transition has not improved identification of rapidly progressing stage 3 and stage 4 chronic kidney disease patients: a diagnostic test study

BACKGROUND

The International Classification of Diseases (ICD) coding system is the industry standard tool for billing, disease classification, and epidemiology purposes. Prior research has demonstrated ICD codes to have poor accuracy, particularly in relation to rapidly progressing chronic kidney disease (CKD) patients. In 2016, the ICD system moved to revision 10. This study examines subjects in a large insurer database to determine the accuracy of ICD-10 CKD-staging codes to diagnose patients rapidly progressing towards end-stage kidney disease (ESKD).

PATIENTS AND METHODS

Serial observations of outpatient serum creatinine measurements from 2016 to 2021 of 315,903 patients were transformed to estimated glomerular filtration rate (eGFR) to identify CKD stage-3 and advanced patients diagnosed clinically (eGFR-CKD). CKD-staging codes from the same time period of 59,386 patients and used to identify stage-3 and advanced patients diagnosed by ICD-code (ICD-CKD). eGFR-CKD and ICD-CKD diagnostic accuracy was compared between a total of 334,610 patients.

RESULTS

5,618 patients qualified for the progression analysis; 72 were identified as eGFR rapid progressors; 718 had multiple codes to qualify as ICD rapid progressors. Sensitivity was 5.56%, with positive predictive value (PPV) 5.6%. 34,858 patients were diagnosed as eGFR-CKD stage-3 patients; 17,549 were also diagnosed as ICD-CKD stage-3 patients, for a sensitivity of 50.34%, with PPV of 58.71%. 4,069 patients reached eGFR-CKD stage-4 with 2,750 ICD-CKD stage-4 patients, giving a sensitivity of 67.58%, PPV of 42.43%. 959 patients reached eGFR-CKD stage-5 with 566 ICD-CKD stage-5 patients, giving a sensitivity of 59.02%, PPV of 35.85%.

CONCLUSION

This research shows that recent ICD revisions have not improved identification of rapid progressors in diagnostic accuracy, although marked increases in sensitivity for stage-3 (50.34% vs. 24.68%), and PPV in stage-3 (58.71% vs. 40.08%), stage-4 (42.43% vs. 18.52%), and stage-5 (35.85% vs. 4.51%) were observed. However, sensitivity in stage-5 compares poorly (59.02% vs. 91.05%).

Quality indicators for primary health care in chronic kidney disease in the public service of a city in the State of São Paulo, Brazil

Abstract: Complications of chronic kidney disease (CKD) can be avoided when promptly diagnosed and treated. The objective was to describe quality indicators of CKD detection and health care in the primary care public service of a city in the State of São Paulo, Brazil. This retrospective study analyzed charts of patients who attended primary care in the public service between November 2019 and February 2020. We selected 10 health quality indicators based on their scientific relevance and availability from the medical records that could express how CKD was identified and managed in primary health care. We estimated the adequate percentage of health indicators with data from 1,066 individuals who had ≥ one risk factor for CKD: hypertension, diabetes, or > 60 years old. Among patients, 79.4% had information on serum creatinine, whereas 58.8% were investigated for proteinuria. Blood pressure data were found in 98.9% of the records. The percentage of patients with blood pressure < 140x90mmHg, glycosylated hemoglobin < 6.5% and LDL-cholesterol < 100mg/dL was 79.2%, 49.2%, and 33.3%, respectively. Renin-angiotensin system blockers were prescribed to 82.8% of the patients with hypertension and CKD. Serum potassium was measured in 35.7% for those who were using renin-angiotensin system blockers. Among those people with CKD, 16.7% had CKD assigned in the medical records as a diagnose. Among those participants at higher risk for CKD, the referral rate to a nephrologist was 31.6%. This study confirmed some missed quality indicators of CKD in primary healthcare. Our results may help administrators develop public policies that improve health care for individuals at high risk for CKD. Long-term follow-up of the health indicators we proposed here will be useful to assess the impact of policy intervention.

Non-steroidal anti-inflammatory drugs in chronic kidney disease: a systematic review of prescription practices and use in primary care

BACKGROUND

Chronic kidney disease (CKD) management focuses on limiting further renal injury, including avoiding nephrotoxic medications such as non-steroidal anti-inflammatory drugs (NSAIDs). We performed a systematic review to evaluate the prevalence of primary care NSAID prescribing in this population.

METHODS

We systematically searched MEDLINE and Embase from inception to October 2017 for observational studies examining NSAID prescribing practices or use in CKD patients in a primary care setting. The methodological quality of included studies was assessed independently by two authors using a modified version of the Agency for Healthcare Research and Quality's Methodological Evaluation of Observational Research checklist.

RESULTS

Our search generated 8055 potentially relevant publications, 304 of which were retrieved for full-text review. A total of 14 studies from 13 publications met our inclusion criteria. There were eight cohort and three cross-sectional studies, two quality improvement intervention studies and one prospective survey, representing a total of 49 209 CKD patients. Cross-sectional point prevalence of NSAID use in CKD patients ranged from 8 to 21%. Annual period prevalence rates ranged from 3 to 33%. Meta-analysis was not performed due to important clinical heterogeneity across study populations.

CONCLUSIONS

Evidence suggests that NSAID prescriptions/use in primary care among patients with CKD is variable and relatively high. Future research should explore reasons for this to better focus knowledge translation interventions aimed at reducing NSAID use in this patient population.

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

BACKGROUND AND OBJECTIVES

Improving the quality of CKD care has important public health implications to delay disease progression and prevent ESKD. National trends of the quality of CKD care are not well established. Furthermore, it is unknown whether gaps in quality of care are due to lack of physician awareness of CKD status of patients or other factors.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We performed a national, serial, cross-sectional study of visits to office-based ambulatory care practices for adults with diagnosed CKD from the years 2006 to 2014. We assessed the following quality indicators: (1) BP measurement, (2) uncontrolled hypertension, (3) uncontrolled diabetes, (4) angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use among patients with hypertension, (5) statin use if age ≥50 years old, and (6) nonsteroidal anti-inflammatory drug use. Using multivariable linear regression and chi-squared analysis, we examined the change in quality performance over time.

RESULTS

Between 2006 and 2014, there were 7099 unweighted visits for patients with CKD representing 186,961,565 weighted visits. There was no difference in the prevalence of uncontrolled hypertension (>130/80 mm Hg) over time (46% in 2006-2008 versus 48% in 2012-2014; P=0.50). There was a high prevalence of uncontrolled diabetes in 2012-2014 (40% for hemoglobin A1c >7%). The prevalence of ACEi/ARB use decreased from 45% in 2006-2008 to 36% in 2012-2014, which did not reach statistical significance (P=0.07). Statin use in patients with CKD who were 50 years or older was low and remained unchanged from 29% in 2006-2008 to 31% in 2012-2014 (P=0.92).

CONCLUSIONS

In a nationally representative dataset, we found that patients with CKD had a high prevalence of uncontrolled hypertension and diabetes and a low use of statins that did not improve over time and was not concordant with guidelines.

Prescribing quality in secondary care patients with different stages of chronic kidney disease: a retrospective study in the Netherlands

OBJECTIVES

Insight in the prescribing quality for patients with chronic kidney disease (CKD) in secondary care is limited. The aim of this study is to assess the prescribing quality in secondary care patients with CKD stages 3-5 and possible differences in quality between CKD stages.

DESIGN

This was a retrospective cohort study.

SETTING

Data were collected at two university (n=569 and n=845) and one non-university nephrology outpatient clinic (n=1718) in the Netherlands.

PARTICIPANTS

Between March 2015 and August 2016, data were collected from patients with stages 3a-5 CKD seen at the clinics. Blood pressure measurements, laboratory measurements and prescription data were extracted from medical records. For each prescribing quality indicator, patients with incomplete data required for calculation were excluded.

OUTCOME MEASURES

Potentially appropriate prescribing of antihypertensives, renin-angiotensin-aldosterone system (RAAS) inhibitors, statins, phosphate binders and potentially inappropriate prescribing according to prevailing guidelines was assessed using prescribing quality indicators. Χ² or Fisher's exact tests were used to test for differences in prescribing quality.

RESULTS

RAAS inhibitors alone or in combination with diuretics (57% or 52%, respectively) and statins (42%) were prescribed less often than phosphate binders (72%) or antihypertensives (94%) when indicated. Active vitamin D was relatively often prescribed when potentially not indicated (19%). Patients with high CKD stages were less likely to receive RAAS inhibitors but more likely to receive statins when indicated than stage 3 CKD patients. They also received more active vitamin D and erythropoietin-stimulating agents when potentially not indicated.

CONCLUSIONS

Priority areas for improvement of prescribing in CKD outpatients include potential underprescribing of RAAS inhibitors and statins, and potential overprescribing of active vitamin D. CKD stage should be taken into account when assessing prescribing quality.

Can billing codes accurately identify rapidly progressing stage 3 and stage 4 chronic kidney disease patients: a diagnostic test study

Background

The International Classification of Diseases (ICD) coding system is the industry standard tool for billing, disease classification, and epidemiology purposes. However, ICD codes are often not assigned or incorrectly given, particularly among Chronic Kidney disease (CKD) patients. Our study evaluated the diagnostic accuracy of CKD-staging ICD codes among CKD patients from a large insurer database in identifying individuals rapidly progressing towards end-stage renal disease (ESRD).

Patients and methods

Serial observations including outpatient serum creatinine measurements collected from 2007 through 2014 of 216,529 patients were examined. The progression of CKD using a serum creatinine based longitudinal mixed-model was contrasted with that documented by CKD-staging ICD codes. Rapid progressors, defined as those with yearly estimated glomerular filtration rate (eGFR) loss greater than 4 ml/min/1.73m²) were identified. The diagnosis of CKD using eGFR was also compared to diagnosis using a set of CKD related ICD codes.

Results

Of 10,927 clinically identified CKD patients qualifying for inclusion in the progression analysis, 323 were clinically identified as rapid progressors. CKD-staging ICD codes identified 83 of these, for a sensitivity of 25.7% with positive predictive value (PPV) of 13.74%, and specificity 95.09% with negative predictive value (NPV) of 97.68%. Of 28,762 laboratory-confirmed CKD patients, 9249 had a qualifying ICD code, for a sensitivity of 16% with PPV of 63.10%; Of 187,767 patients with laboratory-confirmed absence of CKD, 182,359 also did not have a qualifying ICD code, for a specificity of 97.12% with NPV of 90.33%.

Conclusion

This study depicts the novel finding that ICD-codes display poor capacity to identify rapidly progressing CKD patients when compared to gold standard eGFR measures, and further demonstrates the limitations of coding in CKD diagnosis. This analysis further defines the limitations of ICD codes in addressing diagnosis of disease severity or disease progression for clinical or epidemiological purposes.

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1429-4) contains supplementary material, which is available to authorized users.

Risk Factors for Unplanned Dialysis Initiation: A Systematic Review of the Literature

Background:

Unplanned dialysis initiation is common in patients with chronic kidney disease (CKD).

Objective:

To determine common definitions and patient risk factors for unplanned dialysis.

Design:

Systematic review.

Setting:

MEDLINE, EMBASE, and the Cochrane Library were searched from inception to February 2018.

Patients:

Studies that included incident chronic dialysis patients or patients with CKD that cited a definition or examined risk factors for unplanned dialysis were included.

Measurements:

Definitions and criteria for unplanned dialysis reported across studies. Patient characteristics associated with unplanned dialysis.

Methods:

Two reviewers independently extracted data using a standardized data abstraction form and assessed study quality using a modified New Castle Ottawa Scale.

Results:

From 2797 citations, 48 met eligibility criteria. Reported definitions for unplanned dialysis were variable. Most publications cited dialysis initiation under emergency conditions and/or with a central venous catheter. The association of patient characteristics with unplanned dialysis was reported in 26 studies, 18 were retrospective and 21 included incident dialysis patients. The most common risk factors in univariate analyses were (number of studies) increased age (n = 7), cause of kidney disease (n = 6), presence of cardiovascular disease (n = 7), lower serum hemoglobin (n = 9), lower serum albumin (n = 10), higher serum phosphate (n = 6), higher serum creatinine or lower estimated glomerular filtration rate (eGFR) at dialysis initiation (n = 7), late referral (n = 5), lack of dialysis education (n = 6), and lack of follow-up in a predialysis clinic prior to dialysis initiation (n = 5). A minority of studies performed multivariable analyses (n = 10); the most common risk factors were increased age (n = 4), increased comorbidity score (n = 3), late referral (n = 5), and lower eGFR at dialysis initiation (n = 3).

Limitations:

Comparison of results across studies was limited by inconsistent definitions for unplanned dialysis. High-quality data on patient risk factors for unplanned dialysis are lacking.

Conclusions:

Well-designed prospective studies to determine modifiable risk factors are needed. The lack of a consensus definition for unplanned dialysis makes research and quality improvement initiatives in this area more challenging.

Process quality indicators for chronic kidney disease risk management: a systematic literature review

BACKGROUND AND OBJECTIVES

Quality indicators (QIs) can be used for measuring the quality of actions of healthcare providers. This systematic review gives an overview of such QIs measuring processes of care for chronic kidney disease (CKD), and identifies the QIs that have content, face, operational and/or predictive validity.

METHODS

PubMed and Embase were searched using a strategy combining the terms "quality of care," "quality indicators" and "chronic kidney disease". Papers were included if they focused on developing, testing or applying QIs for assessing the quality of care in adult patients with CKD not on renal replacement therapy.

RESULTS

Two hundred and seventy-three QIs from thirty-one papers were extracted, including QIs on adequate monitoring of kidney function and vascular risk factors, on indicated treatment, drug safety, adherence and referral to a specialist. The QIs that were considered content, face and operational valid focused on monitoring of glomerular filtration rate, albumin-creatinine ratio, lipid levels and blood pressure, the use of non-steroidal anti-inflammatory drugs, nitrofurantoin and biphosphonates in patients with CKD, and QIs on monitoring haemoglobin and treatment with angiotensin-converting-enzyme-inhibitors/angiotensin-receptor-II-blockers in patients with CKD and comorbidities. No QIs were tested for predictive validity. In addition, only two QIs focused on diet and no other QIs focused on lifestyle management.

CONCLUSIONS

Based on this review, sufficiently validated QIs can be selected for measuring the quality of CKD care. This review provides insight in QIs that need further validation, and in areas of care where QIs are still lacking.