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Adherence to Guideline-Recommended Care for Veterans with Chronic Kidney Disease in VA

Chen G, Egede LE, Moran WP. Adherence to Guideline-Recommended Care for Veterans with Chronic Kidney Disease in VA. Journal of general internal medicine. 2010 Jan 1; 25(Suppl 3):S219.

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Background: Chronic kidney disease (CKD) is prevalent in primary care. Primary care physicians play a critical role in diagnosis and ongoing care for patients with pre-dialysis CKD. Practice guidelines for the treatment of patients with chronic kidney disease (CKD) recommend several laboratory tests to monitor status of kidney function, anemia, nutrition, and bone metabolism. Little is known about how well the guidelines have been followed in VA practice setting. The objective of this study was to evaluate adherence to CKD clinical practice treatment recommendations for patients with pre-dialysis CKD seen in the VA healthcare system. Methods: This was a retrospective cohort study of Veterans that received care at primary care clinics within one Veteran Integrated Service Network (VISN) in the Southwest. VA clinical and lab data in FY2002-2003 were used in this analysis. The abbreviated modification of diet in renal disease (MDRD) equation was used to derive an estimated glomerular filtration rate (eGFR). Subjects were included in the study cohort 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 fiscal year 2002. The date of the second abnormal serum creatinine test was used as the index CKD date for tracking adherence to clinical guideline testing recommendations. The selected tests included serum creatinine, hemoglobin, albumin, and total cholesterol. The endpoints of the study were that patients in the cohort would receive at least one test for each recommended measure over 12 months of the follow-up. Descriptive and multivariate regression analyses were performed. Results: Of 13,677 patients in the cohort, 78.72%, 11.87%, 1.96%, and 7.46% were White, African- American, Other, and unknown race respectively. The mean age was 71 (SD = 9.5) and 97.27% were male. Majority of 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 that 98.5% of patients received at least one serum creatinine test, 79.0% got a total cholesterol check, 76.2% got a hemoglobin check, 69.9% had their HDL-C checked, 59.5% had their LDL-C checked and 68.5% had a serum albumin test. In multivariate models, having multiple comorbidities were associated with increased likelihood of receiving hemoglobin, lipid, and albumin tests, while being older age and being an African American was associated with decreased likelihood of receiving lipid and serum albumin tests. Conclusions: This study shows that adherence to guidelines on serum creatinine testing frequency in veterans with pre-dialysis CKD was high in primary care. However, frequency of testing was less than ideal for monitoring of anemia, lipid control, and nutritional status in the follow-up care for CKD. While multiple comorbidity was associated with increased testing, older age and African American ethnicity were associated with decreased receipt of lipid and serum albumin tests. Future studies should explore physicians' barriers and facilitators in practicing guideline-recommended care for veterans with CKD in VA outpatient settings.

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