TY - JOUR
T1 - Nephrology co-management versus primary care solo management for early chronic kidney disease
T2 - A retrospective cross-sectional analysis Epidemiology and Health Outcomes
AU - Samal, Lipika
AU - Wright, Adam
AU - Waikar, Sushrut S.
AU - Linder, Jeffrey A.
N1 - Funding Information:
We would like to acknowledge Julie Fiskio, MS for data retrieval, Stuart Lipsitz, PhD for assistance with statistical techniques to adjust for clustering, and Julia Whelan, MS AHIP, for literature retrieval. The corresponding author affirms that all people contributing significantly to the work have been acknowledged. Written permission has been obtained from all persons named in the acknowledgment. Research reported in this publication was supported by the National Institute of Diabetes And Digestive And Kidney Diseases of the National Institutes of Health under Award Number K23DK097187. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Publisher Copyright:
© 2015 Samal et al.
PY - 2015/10/12
Y1 - 2015/10/12
N2 - Background: Primary care physicians (PCPs) typically manage early chronic kidney disease (CKD), but recent guidelines recommend nephrology co-management for some patients with stage 3 CKD and all patients with stage 4 CKD. We sought to compare quality of care for co-managed patients to solo managed patients. Methods: We conducted a retrospective cross-sectional analysis. Patients included in the study were adults who visited a PCP during 2009 with laboratory evidence of CKD in the preceding two years, defined as two estimated glomerular filtration rates (EGFR) between 15-59 mL/min/1.73 m2 separated by 90 days. We assessed process measures (serum EGFR test, urine protein/albumin test, angiotensin converting enzyme inhibitor or angiotensin receptor blocker [ACE/ARB] prescription, and several tests monitoring for complications) and intermediate clinical outcomes (mean blood pressure and blood pressure control) and performed subgroup analyses by CKD stage. Results: Of 3118 patients, 11 % were co-managed by a nephrologist. Co-management was associated with younger age (69 vs. 74 years), male gender (46 % vs. 34 %), minority race/ethnicity (black 32 % vs. 22 %; Hispanic 13 % vs. 8 %), hypertension (75 % vs. 66 %), diabetes (42 % vs. 26 %), and more PCP visits (5.0 vs. 3.9; p < 0.001 for all comparisons). After adjustment, co-management was associated with serum EGFR test (98 % vs. 94 %, p = <0.0001), urine protein/albumin test (82 % vs 36 %, p < 0.0001), and ACE/ARB prescription (77 % vs. 69 %, p = 0.03). Co-management was associated with monitoring for anemia and metabolic bone disease, but was not associated with lipid monitoring, differences in mean blood pressure (133/69 mmHg vs. 131/70 mmHg, p > 0.50) or blood pressure control. A subgroup analysis of Stage 4 CKD patients did not show a significant association between co-management and ACE/ARB prescription (80 % vs. 73 %, p = 0.26). Conclusion: For stage 3 and 4 CKD patients, nephrology co-management was associated with increased stage-appropriate monitoring and ACE/ARB prescribing, but not improved blood pressure control.
AB - Background: Primary care physicians (PCPs) typically manage early chronic kidney disease (CKD), but recent guidelines recommend nephrology co-management for some patients with stage 3 CKD and all patients with stage 4 CKD. We sought to compare quality of care for co-managed patients to solo managed patients. Methods: We conducted a retrospective cross-sectional analysis. Patients included in the study were adults who visited a PCP during 2009 with laboratory evidence of CKD in the preceding two years, defined as two estimated glomerular filtration rates (EGFR) between 15-59 mL/min/1.73 m2 separated by 90 days. We assessed process measures (serum EGFR test, urine protein/albumin test, angiotensin converting enzyme inhibitor or angiotensin receptor blocker [ACE/ARB] prescription, and several tests monitoring for complications) and intermediate clinical outcomes (mean blood pressure and blood pressure control) and performed subgroup analyses by CKD stage. Results: Of 3118 patients, 11 % were co-managed by a nephrologist. Co-management was associated with younger age (69 vs. 74 years), male gender (46 % vs. 34 %), minority race/ethnicity (black 32 % vs. 22 %; Hispanic 13 % vs. 8 %), hypertension (75 % vs. 66 %), diabetes (42 % vs. 26 %), and more PCP visits (5.0 vs. 3.9; p < 0.001 for all comparisons). After adjustment, co-management was associated with serum EGFR test (98 % vs. 94 %, p = <0.0001), urine protein/albumin test (82 % vs 36 %, p < 0.0001), and ACE/ARB prescription (77 % vs. 69 %, p = 0.03). Co-management was associated with monitoring for anemia and metabolic bone disease, but was not associated with lipid monitoring, differences in mean blood pressure (133/69 mmHg vs. 131/70 mmHg, p > 0.50) or blood pressure control. A subgroup analysis of Stage 4 CKD patients did not show a significant association between co-management and ACE/ARB prescription (80 % vs. 73 %, p = 0.26). Conclusion: For stage 3 and 4 CKD patients, nephrology co-management was associated with increased stage-appropriate monitoring and ACE/ARB prescribing, but not improved blood pressure control.
KW - Ambulatory care
KW - Kidney diseases
KW - Nephrology
KW - Primary care
KW - Quality of healthcare
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UR - http://www.scopus.com/inward/citedby.url?scp=84959189808&partnerID=8YFLogxK
U2 - 10.1186/s12882-015-0154-x
DO - 10.1186/s12882-015-0154-x
M3 - Article
C2 - 26458541
AN - SCOPUS:84959189808
SN - 1471-2369
VL - 16
JO - BMC Nephrology
JF - BMC Nephrology
IS - 1
M1 - 162
ER -
