Documentation and management of CKD in rural primary care

Screening for chronic kidney disease in a hypertensive primary care cohort

BACKGROUND

Screening rates for chronic kidney disease (CKD) in primary care settings remain low. Although primary care providers are well positioned to offer this testing, there are many barriers that contribute to low screening rates.

PURPOSE

The purpose of this study was to examine both practice and contextual factors that relate to screening for CKD in a cohort of primary care patients with hypertension.

METHODS

A mixed-methods, single-embedded, convergent parallel design was used for this organizational case study. The Chronic Care Model served as the framework. Electronic medical record data, resource walk-through, and provider surveys were collected from selected primary care clinics within one large academic medical center in the Pacific Northwest. Analyses included regression models, descriptive statistics, narrative content analysis, and pattern matching for organizational case creation.

RESULTS

Screening rates were low in the cohort, but patients with more risk factors for CKD were more likely to receive orders for screening. Organizational and community support was deemed necessary for primary care providers to effectively translate guidelines into practice.

IMPLICATIONS FOR PRACTICE

The results of this study offer support for a wholistic approach to guideline translation into practice. Participants in the study were open to increased screening for CKD but needed support in multiple ways from the organization. Guidelines alone were not deemed the ideal vehicles for translation of research into practice.

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

BACKGROUND

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Chronic kidney disease care in the US safety net

The US Health Care System provides a patchwork of services, known as the safety net, for the uninsured, underinsured, and indigent populations who would otherwise have little access to health care services. Individuals who rely on safety-net facilities are from racial/ethnic minority groups, have low socioeconomic status, and often have low health literacy and/or limited English proficiency. They shoulder a disproportionate burden of CKD in the United States and experience excess CKD-associated morbidity and mortality. Suboptimal delivery of CKD care may be contributing and is an area of active translational research. Several initiatives that show promise in improving safety-net CKD care delivery include those that enhance diagnostic and management skills of primary care providers, rely on comprehensive care management programs led by nonphysicians, and leverage technology to enhance patient access to virtual nephrology expertise. Uncovering better ways to translate scientific evidence into practice for vulnerable patients with CKD is a formidable challenge that will require national surveillance of CKD quality measures across diverse ambulatory health systems, including safety nets. Only then will the nephrology community be to identify and share best practices to enhance health and mitigate disparities of care among patients with CKD.

Chronic kidney disease in general populations and primary care: diagnostic and therapeutic considerations

PURPOSE OF REVIEW

The majority of people with chronic kidney disease (CKD) are managed by primary care physicians and nurses, but much of the initial research on CKD care was based in secondary care. The purpose of this article is to review the important recent studies of CKD in primary care that are starting to provide an evidence base for the strategies to improve the management and outcomes of the unreferred majority of people with CKD.

RECENT FINDINGS

People with CKD in primary care populations differ substantially from those familiar to nephrologists in secondary care by being older, having less reduction in glomerular filtration rate (GFR) and lower prevalence of proteinuria. These differences have important implications for management priorities. Detailed studies have identified widespread deficiencies in the care of patients with CKD in primary care (though these are also reported in secondary care). Interventions that may improve performance include automated reporting of estimated GFR, incentivizing primary care practitioners to achieve therapeutic goals and quality improvement strategies such as audit-based education.

SUMMARY

Studies have identified a need for improved management of CKD in primary care as well as methods to achieve this. Future studies should focus on the promotion of self-management through telemedicine and the Internet.

Chronic kidney disease in an electronic health record problem list: quality of care, ESRD, and mortality

BACKGROUND

Whether chronic kidney disease (CKD) recognition in an electronic health record (EHR) problem list improves processes of care or clinical outcomes of end-stage renal disease (ESRD) and death is unclear.

METHODS

We identified patients who had at least 1 year of follow-up (2005-2009) in our EHR-based CKD registry (n = 25,742). CKD recognition was defined by having ICD-9 codes for CKD, diabetic kidney disease, or hypertensive kidney disease in the problem list. We calculated proportions of patients with and without CKD recognition and examined differences by demographics, clinical factors, and development of ESRD or mortality. We evaluated differences in the proportion of patients with CKD-specific laboratory results checked before and after recognition among cases and propensity-matched controls.

RESULTS

Only 11% (n = 2,735) had CKD recognition in the problem list and they were younger (68 vs. 71 years), a higher proportion were male (61 vs. 37%) and African-American (21 vs. 10%) compared to those unrecognized. CKD-specific laboratory results for patients with estimated glomerular filtration rate (eGFR) 30-59 including intact parathyroid hormone (23 vs. 6%), vitamin D (22 vs. 18%), phosphorus (29 vs. 7%), and a urine check for proteinuria (55 vs. 36%) were significantly more likely to be done among those with CKD recognition (all p < 0.05). Similar results were found for eGFR <30 except for proteinuria and in our propensity score-matched control analysis. There was no independent association of CKD recognition with ESRD or mortality.

CONCLUSIONS

CKD recognition in the EHR problem list was low, but translated into more CKD-specific processes of care; however ESRD or mortality were not affected.