As Trump Outlines Plans, Major Gaps in Kidney Disease Care Unveiled

Veronica Hackethal, MD

July 12, 2019

A nationwide US study has uncovered major gaps in quality, guideline-oriented care for chronic kidney disease (CKD), as detailed in a new study published online July 11 in the Clinical Journal of the American Society of Nephrology.

The results reveal that care among individuals with CKD has not improved over 10 years.

"CKD, where kidney function is reduced or the kidney shows signs of damage, is a major public health problem. Controlling risk factors, such as high blood pressure and diabetes, and using evidence-based medications in patients with CKD is especially critical to decrease the risk of kidney failure," lead author Sri Lekha Tummalapalli, MD, MBA, University of California, San Francisco, said in a press release by the American Society of Nephrology.

Specifically, rates of uncontrolled hypertension stayed the same over the decade studied, and rates of uncontrolled diabetes were high. And use of angiotensin-converting enzyme (ACE) inhibitors/angiotensin-receptor blockers (ARBs) — which studies have shown may decrease progression to end-stage renal disease (ESRD) — actually decreased.

Meanwhile, guideline-recommended statins are substantially underused among individuals with CKD. But use of nonsteroidal anti-inflammatory drugs (NSAIDs), which the American Board of Medicine recommends should be avoided in CKD, has increased slightly.

The findings highlight "a more urgent need for CKD-specific quality measures and implementation of quality improvement interventions," the researchers stress.

National Conversation About CKD

About 30 million Americans suffer from CKD, according to background information in the new article. Improving care for these people has the potential to improve health and delay progression to kidney failure.

"There is a national conversation happening right now about kidney disease. National professional organizations, government, and insurance are coalescing to improve care models for kidney disease," Tummalapalli noted.

Indeed, earlier this week, the Trump administration signed an executive order for changing the Medicare payment for ESRD, with a focus on increasing kidney donation and home dialysis, as reported by Medscape Medical News.

"Preventing kidney failure and decreasing the risk of other complications, such as heart disease, starts at early stages of CKD. Our research highlights the current gaps in care," Tummalapalli stressed.

Past studies have suggested poor quality of care for patients with CKD, but few have looked at nationwide trends for the issue, say Tummalapalli and coauthors.

So they conducted their nationwide cross-sectional study using data from the National Ambulatory Medical Care Survey (NAMCS), a sampling of office-based care in the United States. The analysis included office visits for adults with CKD from 2006-2014 (7099 unweighted visits, representing 186,961,565 weighted visits).

Researchers evaluated the following indicators of quality care: blood pressure, uncontrolled hypertension, uncontrolled diabetes, ACE inhibitor or ARB use among patients with hypertension, statin use among individuals aged 50 and older, and NSAID use.

Results were adjusted for age, sex, and presence of hypertension, diabetes, congestive heart failure, and cardiovascular disease.

No Change in Uncontrolled Hypertension Over 10 Years

The percentage of office visits during which blood pressure was measured increased from 89% in 2006-2008 and 2009-2011 to 93% in 2012-2014 (adjusted P for trend = .02).

However, the prevalence of uncontrolled hypertension (> 130/80 mmHg) remained the same over time (46% in 2006-2008 vs 48% in 2012-2014; adjusted P = .27).

The prevalence of uncontrolled diabetes was also high in 2012-2014. (During this period, 40% of patients had an HbA1c > 7% and 24% had an HbA1c > 8%. No data were reported for the earlier study period.)

Use of ACE inhibitors/ARBs decreased from 45% in 2006-2008 to 36% in 2012-2014. Although the unadjusted results were not significantly different (P = .07), they became significant after adjusting for confounders (P = .003).

And among patients with CKD who were 50 years or older, statin use remained far below guideline recommendations, at 29% in 2006-2008 and 31% in 2012-2014 (adjusted P = .66).

Use of NSAIDs increased slightly from 2% in 2006-2008 to 4% in 2012-2014 (adjusted P = .01).

To Improve CKD Care, We Must Include Primary Care Physicians

The authors mentioned several limitations. NAMCS lacked data that could confirm the diagnosis of CKD and appropriateness of ACE inhibitor/ARB prescribing. And the study did not include data on veterans or individuals in institutions like nursing homes.

Nevertheless, they stress: "In a nationally representative dataset, we found that patients with CKD had a high prevalence of uncontrolled hypertension and diabetes and a low use of statins that did not improve over time and was not concordant with guidelines."

"Even when physicians are aware of a patient's CKD diagnosis, there are substantial gaps in quality of CKD care. 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," they conclude.

The study was funded by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases. The authors have reported no relevant financial relationships.

CJASN. Published online July 11, 2019. Abstract

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