In the JournalsPerspective

No improvements seen in CKD care over nearly a decade with treatment guidelines not followed

The quality of care for patients with CKD showed no improvements between 2006 and 2014, with recommended treatments frequently underused, according to a recently published study.

“Improving the quality of CKD care has important public health implications to delay disease progression and prevent ESKD,” Sri Lekha Tummalapalli, MD, MBA, of the University of California San Francisco, and colleagues wrote. “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. In this study we assess temporal trends in the quality of CKD care [and] we examine the quality of CKD care among patients with physician-diagnosed CKD as a proxy for physician CKD awareness.”

Researchers conducted a national, serial, cross-sectional study of patients with CKD who visited office-based ambulatory care practices between 2006 and 2014 (mean age, 69 years; 53% men; 69% non-Hispanic white).

Considered factors included blood pressure measurement, uncontrolled hypertension (defined as > 130/80 mm Hg), uncontrolled diabetes (HbA1c > 7%), angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use among patients with hypertension, statin use in patients 50 years or older and nonsteroidal anti-inflammatory drug use.

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The quality of care for patients with CKD showed no improvements between 2006 and 2014, with recommended treatments frequently underused.
Source: Adobe Stock

Change in quality performance over time was calculated using multivariable linear regression and chi-squared analysis.

Investigators found that uncontrolled diabetes occurred in 40% of patients between 2012 and 2014 and that, over time, there was no difference in the prevalence of uncontrolled hypertension (46% in 2006-2008 vs. 48% in 2012-2014).

Regarding treatment guidelines, the use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers declined from 45% between 2006 and 2008 to 36% between 2012 and 2014 and statin use was consistently low, with a prevalence of 29% between 2006 and 2008 and 31% between 2012 and 2015.

“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,” the researchers wrote. “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 multi-specialty care teams. Primary care physicians may have skepticism that monitoring CKD improves care, which may drive worse quality. Additional barriers include limited time, competing demands, and difficulties obtaining and using data. Effective management of hypertension and diabetes requires medication adherence and patient behavior change, which is difficult to achieve.

[There is] an urgent need for CKD-specific quality measures and implementation of quality improvement interventions.” – by Melissa J. Webb

Disclosures: Tummalapalli reports support from the National Institute of Diabetes and Digestive Kidney Diseases 2T32DK007219-41 Training Grant to the University of California San Francisco. The other authors report no relevant financial disclosures.

The quality of care for patients with CKD showed no improvements between 2006 and 2014, with recommended treatments frequently underused, according to a recently published study.

“Improving the quality of CKD care has important public health implications to delay disease progression and prevent ESKD,” Sri Lekha Tummalapalli, MD, MBA, of the University of California San Francisco, and colleagues wrote. “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. In this study we assess temporal trends in the quality of CKD care [and] we examine the quality of CKD care among patients with physician-diagnosed CKD as a proxy for physician CKD awareness.”

Researchers conducted a national, serial, cross-sectional study of patients with CKD who visited office-based ambulatory care practices between 2006 and 2014 (mean age, 69 years; 53% men; 69% non-Hispanic white).

Considered factors included blood pressure measurement, uncontrolled hypertension (defined as > 130/80 mm Hg), uncontrolled diabetes (HbA1c > 7%), angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use among patients with hypertension, statin use in patients 50 years or older and nonsteroidal anti-inflammatory drug use.

#
The quality of care for patients with CKD showed no improvements between 2006 and 2014, with recommended treatments frequently underused.
Source: Adobe Stock

Change in quality performance over time was calculated using multivariable linear regression and chi-squared analysis.

Investigators found that uncontrolled diabetes occurred in 40% of patients between 2012 and 2014 and that, over time, there was no difference in the prevalence of uncontrolled hypertension (46% in 2006-2008 vs. 48% in 2012-2014).

Regarding treatment guidelines, the use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers declined from 45% between 2006 and 2008 to 36% between 2012 and 2014 and statin use was consistently low, with a prevalence of 29% between 2006 and 2008 and 31% between 2012 and 2015.

“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,” the researchers wrote. “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 multi-specialty care teams. Primary care physicians may have skepticism that monitoring CKD improves care, which may drive worse quality. Additional barriers include limited time, competing demands, and difficulties obtaining and using data. Effective management of hypertension and diabetes requires medication adherence and patient behavior change, which is difficult to achieve.

[There is] an urgent need for CKD-specific quality measures and implementation of quality improvement interventions.” – by Melissa J. Webb

Disclosures: Tummalapalli reports support from the National Institute of Diabetes and Digestive Kidney Diseases 2T32DK007219-41 Training Grant to the University of California San Francisco. The other authors report no relevant financial disclosures.

    Perspective
    Keith Bellovich

    Keith Bellovich

    In the article by Tummalapalli and colleagues, profound gaps in care according to multiple, well-established clinical guidelines for patients diagnosed with CKD continue to be exposed. In a careful analysis of the National Ambulatory Medical Care Survey from 2006 through 2014, patients with the diagnosis of CKD had a high prevalence of uncontrolled hypertension ranging from 46% to 48%, a high prevalence of uncontrolled diabetes mellitus and use of ACEi/ARB in this population actually decreased over time. In addition, statin use in patients with CKD who were older than 50 years who are undoubtedly at greatest risk of cardiovascular events remain low and unchanged over that same time period.

    It is apparent that we as a medical community have tremendous opportunity to improve care delivery to our CKD population at risk. Despite using office-based blood pressure readings — granted, not the ideal marker — I doubt there will be any dispute that less than 50% of the population having suboptimal control without using  ACEi/ARB as part of that regimen is woefully inadequate. These datasets only continue to support prior studies with similar findings in NHANES and the CRIC CKD population cohorts.

    In light of President Trump’s executive order, Advancing American Kidney Health announced on July 10, there is overt intent by federal agencies to avoid kidney disease progression through incentivized payment models in efforts to drive better quality outcomes for patients with CKD. How do we close these gaps effectively now that the ante has been increased by CMS? The recipe has already been well described and the time has come to implement them. Population health management, through accurate measurement of performance and proven quality outcomes using clinical disease registries, becomes imperative. Peter Drucker, the renowned grandfather of quality improvement, said it best: “If you don’t measure it, it will never improve.”

    When we as a health care community review our performance 5 years from now, will we see that this grand experiment in kidney care work? I remain confident we will do better.

    • Keith Bellovich, DO
    • St. Clair Nephrology, PC
      Roseville, Michigan
      Nephrology News & Issues Editorial Advisory Board Member

    Disclosures: Bellovich reports no relevant financial disclosures.