Large gap between norms and actual quality of primary care in Canadian kidney patients

Chronic kidney disease (CKD) is a condition commonly encountered in primary health care the world over. However, a new study published in JAMA Network on September 4, 2019, shows that the standard of primary care is quite variable.

Despite guidelines issued by a host of organizations including the Canadian Society of Nephrology, only 75% of the patients under treatment met at least 4 of 12 quality indicators for treatment, and none at all for diagnosis or monitoring. A simple urine albumin test which is free and easy to do is done in only less than a fifth of patients. The study suggests that there is plenty of room for improvement in ensuring quality care in CKD, which can help reduce the healthcare burden due to ESKD.

Kidney failure requires dialysis or a transplant, and affects about 39,000 Canadians every year. The cost of dialysis for one patient is about $100,000 and the total cost of care for ESKD is about 2-3% of the whole healthcare allocation. This accounts for this study. Researcher Aminu Bello says, “We want to ensure that Canadians with mild or moderate kidney disease get really high-quality care early on, so we can prevent them ending up on dialysis or getting to the stage where they require a kidney transplant to live.”

CKD in the population

CKD occurs in about 10% of the population. Most of these patients will continue with kidney damage lifelong but without progressing to end-stage kidney disease (ESKD) which means they can continue to be treated in such facilities. However, despite the availability of guidelines on the primary care of these patients, great variability exists between patients.

To correct this, quality assessments are first required at all levels, and these themselves must be subject to benchmarks to ensure uniform and standardized evaluations. This study was aimed at looking at how Canadian CKD management met quality indicators. This could help identify limitations in primary care as well as show the potential for use of data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN), a national surveillance system for chronic diseases, to design programs that improve management of specific chronic conditions.

The study

In the current study, the researchers looked at over 46,000 patients, aged 70 years on average, with stage 3-5 CKD. All patients had at least 2 tests showing glomerular filtration rate (eGFR) measurements less than 60 mL/min/1.73 m2 within a period of 3-18 months.

The patients were classified into four groups:

• Patients without either high blood pressure or diabetes (about 17%)
• Patients with high blood pressure only (37%)
• Patients with diabetes only (15%)
• Patients with both hypertension and diabetes (32%)

They looked at quality indicators in CKD care in the following areas:

• Treatment standards
• Diagnosis of CKD
• Testing and monitoring of kidney function
• Use of recommended drugs
• Monitoring treatment with angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs)
• Managing blood pressure
• Monitoring for blood glucose control

If 75% of the patients met quality indicators in any area the targeted quality of care was presumed to have been achieved.

The findings

Overall, they found that only the target was achieved for only 4 of 12 indicators, namely:

• Serum creatinine test within 18 months of diagnosis (testing and monitoring)
• Blood pressure measurement at any point of follow-up (management of blood pressure)
• Maintaining blood pressure at 140/90 or less (ditto)
• HbA1C (glycated hemoglobin) to monitor diabetes during the follow-up period (management of blood glucose)

Quality of care targets were not met for the indicators in other areas.

Subgroup analysis

With regard to the testing and monitoring of kidney function, the gold standard is the urine albumin: creatinine ratio (UACR). This was done in less than 1 in 5 patients during the 6 months after CKD diagnosis, and 27% within 18 months. Less than 40% of patients with an abnormal first urine albumin test had a UACR test within the next 6 months. This is a critical issue since the higher the albumin level in urine, the worse the kidney damage and the higher the risk of a poor outcome such as ESKD or heart disease.

After being diagnosed with CKD, urine albumin testing was least likely in patients aged 18-49 years, and patients aged 75 or above. The figures are about 19% and 12% respectively, compared to 61% in the age group 75-84 years.

Bello says, “It’s a matter of engagement and making primary care more aware that this test is equally important as checking blood pressure. It's an opportunity to have a dialogue about it because we can do better.”

The lowest CKD detection rates were among patients who had neither hypertension nor diabetes (<7%) and highest among those with both (>35%). Among patients offered a serum creatinine test on outpatient basis, 91% of those with both conditions were tested compared to 77% of those without either condition.

About 31% patients received ACEIs or ARBs within the first year of diagnosis. Within the category of patients with urine albumin or diabetes or both, 31% received these medications. The greatest number of prescriptions was for those with hypertension and CKD, and the least for CKD-diabetes patients.

Less than 8% of patients in the 18-49 year age group were treated with recommended medications compared to 44% of patients aged 75-84 years, who were on ACEIs or ARBs. Only 27% of patients on these drugs had serum creatinine testing done within a month of prescription.
More men than women were likely to receive quality-concordant care with respect to 5 of 7 indicators.

Risk factors for poor care

In general, the more advanced the condition, except with stage 5, the more likely the care was to meet quality standards in at least 75% of cases. Older patients aged 85 years and above, and patients with severe (stage 5) CKD were the least likely to meet quality indicators in all areas examined.

This may be because these patients are more ill, are on more medications, do not feel that this treatment is useful or desirable, or may have a limited lifespan. Thus this may not reflect poor care but rather patient-modified and appropriate care.

Sex-related differences are harder to explain and may need more study. Overall, the researchers also point out a practical difficulty faced by primary care practitioners: “The volume of guideline recommendations for primary care is increasing at a rate that is not sustainable for implementation.

For a primary care physician, it would take 7 hours a day to follow all preventive recommendations and 10 hours a day to follow recommendations for 10 chronic diseases.”

However, the current study does allow a careful evaluation of care and practice patterns at present, to select areas which can be improved in a way that is meaningful to the patients.

Journal reference:

Aminu K. Bello, Paul E. Ronksley, Navdeep Tangri, Julia Kurzawa, Mohamed A. Osman,Alexander Singer, Allan K. Grill, Dorothea Nitsch, John A. Queenan, James Wick,Cliff Lindeman, Boglarka Soos, Delphine S. Tuot, Soroush Shojai, K. Scott Brimble, Dee Mangin, and Neil Drummond. Quality of chronic kidney disease management in Canadian primary care. JAMA Network Open 2019;2(9):e1910704. doi:10.1001/jamanetworkopen.2019.10704. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2749238