Quality of care for patients with chronic kidney disease (CKD) remains suboptimal, even among primary care and specialty physicians aware of the patient's diagnosis, researchers found.
The analysis of data from approximately 7,000 U.S. office visits showed that the prevalence of uncontrolled hypertension among patients with CKD was 46% in 2006-2008 and 48% in 2012-2014 (P=0.50), reported Sri Lekha Tummalapalli, MD, of the University of California, San Francisco, and colleagues.
Writing online in the Clinical Journal of the American Society of Nephrology, they noted that the prevalence of uncontrolled diabetes (defined as a glycated hemoglobin greater than 7%) was 40% in 2012-2014, the only time period for which data was available.
Statin use among CKD patients ages 50 and older was low and remained essentially unchanged from 29% in 2006-2008 to 31% in 2012-2014 (P=0.92), the data showed. Angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) use decreased from 45% to 36% during the same time period, but the trend did not reach statistical significance (P=0.07), the researchers found.
"Despite the introduction of multiple national quality reporting programs and CKD-specific guidelines during our study period, we did not see improvement in quality of CKD care over time. Of note, our study describes the quality of CKD care nationally using diagnosis codes rather than laboratory values, capturing patients who were known to have CKD by their physicians and who may have later-stage CKD," Tummalapalli and co-authors wrote.
"Patients with CKD had a high prevalence of uncontrolled hypertension, which did not decrease over time," the team continued. "Despite strong evidence for the efficacy of ACEi/ARB treatment for patients with CKD in reducing progression to end-stage renal disease, we found that ACEi/ARB use declined over time. We found that statins are extremely underused in patients with CKD, despite guideline recommendations and evidence that statins significantly reduce cardiovascular events and mortality in patients with CKD."
For the study, Tummalapalli's group analyzed data from the National Ambulatory Medical Care Survey (NAMCS) from 2006 to 2014. This annual survey, performed by the CDC's National Center for Health Statistics, gathers information on office-based ambulatory care visits in the U.S., excluding federal, military, and institutional facilities. The survey includes information from primary care physicians such as family practitioners, gynecologists, and internists; specialists including cardiologists, dermatologists, and oncologists; and surgeons. Nephrologists are also included, although the analysis could not separate them out, the researchers noted.
Potential reasons for the suboptimal care found, the team said, include the following:
- Lack of dedicated CKD-specific quality metrics
- Low rates of referral to nephrologists
- Limited time, competing demands, and difficulties obtaining and using data among primary care physicians
"The majority of CKD is treated in primary care settings, and therefore, efforts toward improved CKD management must involve primary care physicians as a central component of multispecialty care teams," Tummalapalli and co-authors stated. "New initiatives, such as the National Kidney Foundation's CKDintercept, may enable improved CKD management in primary care."
Actions for Improving Care
Asked for his perspective, Joseph Vassalotti, MD, chief medical officer at the National Kidney Foundation (NKF), who was not involved in the study, discussed some of these new initiatives as well as strategies for improving patient care: "The big picture opportunities for CKD interventions are population health and quality improvement. A major challenge for population health is the dearth of urine testing for CKD," he told MedPage Today via email.
Vassalotti noted that one of the study limitations mentioned by the authors is the inability to assess albuminuria or the urinary albumin-creatinine ratio (uACR), and that other data suggest that people with diabetes at risk for CKD are tested for uACR only about 40% annually, even though clinical practice guidelines from the NKF, the American Diabetes Association, the Kidney Disease Outcomes Quality Initiative, and the Kidney Disease Improving Global Outcomes recommend annual testing.
He added that the CKDintercept initiative is addressing this issue with a Laboratory Engagement Plan and a Kidney Health Evaluation Measure. In addition, NKF's CKD Change Package provides a list of suggested process improvements that ambulatory care physicians can use to improve CKD screening, recognition, and management.
"An area not addressed by Tummalapalli et al because of the study period is sodium-glucose cotransporter-2 inhibitors (SGLT-2i)," Vassalotti continued. "Recent randomized controlled trials support broad implementation of SGLT-2i in type 2 diabetes and particularly type 2 diabetes with CKD, because of improvements in CKD progression as well as reductions in cardiovascular events and death. The implementation of this new drug class and the assessment at a population level demand further effort."
"Lastly," he said, "there are many hopeful signs. An Indian Health Service population health CKD intervention of adults with type 2 diabetes showed a remarkable 54% reduction in incident end-stage renal disease from 1996 to 2013. A TRANSLATE CKD study implemented the CKD metrics of Tummalapalli et al with two clinical decision support approaches, showing small but significant improvements in diabetes control and CKD trajectory."
Other study limitations, Tummalapalli and co-authors wrote, were that the NAMCS dataset did not contain creatinine or urine albumin-to-creatinine ratio measurements, and that lack of laboratory data made it impossible to assess the appropriateness of prescribing ACE inhibitors or ARBs for proteinuria. Finally, the researchers said, the NAMCS sample represents only patients routinely seen in office-based ambulatory medical care, and therefore, may exclude patients who visit a hospital-based outpatient facility and does not represent veterans or those in institutionalized settings.
The study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases.
Tummalapalli and co-authors reported having no conflicts of interest.
Vassalotti reported having no conflicts of interest.
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