Primary care recognition and treatment of chronic kidney disease can be markedly improved with a few approaches
By 2004, 13 percent of the U.S. population suffered from chronic kidney disease (CKD), most likely due to the rise in such risk factors as hypertension, diabetes, and cardiovascular disease. CKD is underdiagnosed and undertreated in primary care practices; however, a new study suggests that a few quality improvement (QI) techniques can markedly improve its diagnosis and treatment. Researchers at the State University of New York at Buffalo, led by Chester H. Fox, M.D., studied the impact of a QI intervention on care of 181 adults with CKD at two underserved primary care practices over a 1-year period. They determined CKD by a glomerular filtration rate (GFR) of less than 60 mL/min, considered moderate or stage 3 CKD (normal GFR is more than 90 mL/min).
The QI intervention used practice enhancement assistants (PEAs), computer decisionmaking support, and academic detailing to boost implementation of CKD guidelines. The PEAs used computer-guided support systems to implement the National Kidney Foundation Kidney Disease Outcome Quality Initiative guidelines, an evidence-based national CKD care guideline, by creating computerized patient-specific recommendations for each provider. A paper version was used in the paper-based practice.
Once approved, reminder notes were put into patient charts to diagnose CKD and/or anemia, discontinue harmful medications, request additional laboratory workups and referrals, intensify chronic disease management, and treat CKD complications. Academic detailing used clinicians to educate physicians about CKD diagnosis and treatment during a monthly luncheon. Use of the QI approach significantly improved recognition of CKD from 21 percent to 79 percent of patients at the practices. Diagnosis of anemia doubled from 33 to 67 percent. Use of the potentially kidney-damaging drugs metformin and nonsteroidal anti-inflammatory drugs slid 50 percent and 41 percent, respectively. Finally, mean GFR increased a small but significant amount from 45.75 to 47.34, which the researchers deemed encouraging.
The study was supported by the Agency for Healthcare Research and Quality (HS16031). More details are in "Improving chronic kidney disease care in primary care practices: An upstate New York practice-based research network (UNYNET) study," by Dr. Fox, Andrew Swanson, B.A., Linda S. Kahn, Ph.D., and others, in the November/December 2008 Journal of the American Board of Family Medicine 21(6), pp. 522-530.
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