Rural-urban Variations in Quality of Care among Veterans with Chronic Kidney Disease

Chen GJ, Yu HJ, Jia H. Rural-urban Variations in Quality of Care among Veterans with Chronic Kidney Disease. Poster session presented at: VA HSR&D Rural Health / VA Office of Rural Health Field-Based Meeting; 2010 May 6; Portland, ME.

BACKGROUND:Chronic kidney disease (CKD) is highly prevalent among VHA enrollees. Practice guidelines for CKD treatment recommend routine monitoring patient status of kidney function, anemia, and nutrition. OBJECTIVES:This study was to examine rural-urban variations in guidelines recommended CKD care among a cohort of VHA users who were diagnosed with CKD and received pre-dialysis CKD within the VHA system. METHODS:This was a retrospective cohort study of Veterans with CKD who received care at primary care clinics within one Veteran Integrated Service Network (VISN) in the Southwest. Study patients' clinical and lab data in fiscal year (FY) 2002-2003 were obtained from VHA. The abbreviated modification of diet in renal disease (MDRD) equation was used to derive an estimated glomerular filtration rate (eGFR). Patients were included in the study if they had two or more outpatient serum creatinine values measured at least 90 days apart that indicated a GFR between 30-59 mL/min/1.73 m2 in FY 2002. The date of the second abnormal serum creatinine test was used as the index CKD date for tracking whether study patients received the guideline-concordance care. The selected quality of care indicators included the monitoring kidney function (serum creatinine test), anemia (hemoglobin test) and nutrition (albumin test). We used a four-category RUCA codes to classify study patients into metropolitan area, micropolitan area, small town, and rural area. The endpoints of the study were that study patients would receive each recommended test at least once within a follow-up timeframe of 12 months post index date. Descriptive and multivariate regression analyses were performed. STATUS:Accepted for poster presentation. FINDINGS:Among the study cohort (N = 13,677), 56.09% were classified as metropolitan, 18.85% as micropolitan, 14.21% as small town, and 10.49% as rural. The mean age of study patients was 71 (SD = 9.5) years, and 97.27% were male. Majority of the patients had hypertension (75.2%). The other common comorbid conditions included diabetes (31.35%), COPD (18.95%), CHF (13.06%), and CVD (9.67%). We found no significant difference in receiving serum creatinine tests between four groups of patients. However, compared with patients in the metropolitan, patients in micropolitan, small town and rural groups were significantly less likely in receiving hemoglobin and albumin tests respectively (p IMPACT:Our findings indicated that Veterans who were diagnosed with CKD and received care within a southeastern VISN were equally likely to receive the guideline-concordance care on monitoring kidney functions. However, significant rural-urban variations were found in the receipt of the monitoring tests for anemia and nutrition status among the study patients. This preliminary study provided useful information for VA policy makers, clinicians, and researchers. Future studies should identify barriers that prevent or delay CKD patients to access to optimal CKD care within the VA healthcare system.