Attainment of guideline targets in EURODOPPS haemodialysis patients: are differences related to a country's healthcare expenditure and nephrologist workforce?

Abstract

Background: In the field of chronic kidney disease, global clinical practice guidelines have been developed and implemented with a view to improving patient care and outcomes. The attainment of international and European guideline targets for haemodialysis patients in European countries has not been audited recently. Hence, we sought to establish whether the attainment of the targets set out in guidelines and inappropriate care are similar across European countries and whether inter-country differences are related to disparities in national healthcare expenditures (as a percentage of gross domestic product) and/or the nephrologist workforce per capita.

Methods: EURODOPPS is the European part of an international, prospective study of a cohort of adult, in-centre, haemodialysed patients. For the current project, 6317 patients from seven European countries were included between 2009 and 2011. Data on laboratory test results and medication prescriptions were extracted from patient records, in order to determine the overall percentage of patients treated according to the international guidelines on anaemia, dyslipidaemia, metabolic acidosis and mineral bone disease. Data related to macroeconomic indices were collected from World Health Organization database and World Bank stats.

Results: Attainment of the targets set in international guidelines was far from complete; only 34.1% of patients attained their target blood pressure and 31.2% attained their target haemoglobin level. Overall, only 5% of the patients attained all of the studied guideline targets. We observed marked inter-country differences in levels of guideline uptake/application and the use of pharmacological agents. The levels of national healthcare expenditures and nephrologist workforce were not correlated with the percentage of patients on-target for ≥50% of the studied variables or with inappropriate care (except for anaemia).

Conclusions: Our analysis of EURODOPPS data highlighted a low overall level of guideline target attainment in Europe and substantial differences between European countries. These inter-country differences did not appear to be linked to macroeconomic determinants.

Keywords: European; audit; guidelines; haemodialysis; prescription; target.

FIGURE 1

Blood pressure and the use of antihypertensive medications. (A) The percentage of patients on- or over-target; (B) the number of antihypertensive drugs taken; (C) the relationship between the target level and the use of antihypertensive medication (T: on-target for blood pressure; OT: over-target for blood pressure; 0: no antihypertensive medications; 1–2: one or two antihypertensive medications; 3: three antihypertensive medications); (D, E) the difference in mean systolic and diastolic blood pressures by country, relative to the UK: unadjusted (left-most bar for each country), adjusted for age, gender, race, diabetes, hypertension and smoking (second bar from the left), further adjusted for medication (second bar from the right) and further adjusted for interdialytic weight gain (right-most bar). ACE inhibitors: angiotensin-converting enzyme inhibitors; ARBs: angiotensin receptor blockers.

FIGURE 2

Hb levels and the use of ESAs. (A) The percentage of patients in each Hb range; (B) the percentage of patients on ESAs; (C) the difference in Hb level for each country, relative to the UK: unadjusted (left-hand bar for each country), adjusted for age, gender, race, diabetes, hypertension and smoking (middle bar), and further adjusted for ESA and iron use (right-hand bar); (D) the relationship between the Hb target level and the use of ESAs (E: ESA use; NE: no ESA use; OT: over-target for Hb levels; T: on-target for Hb levels; BT: below-target for Hb levels).

FIGURE 3

LDL-C levels and the use of statins. (A) The percentage of patients on- or over-target; (B) the percentage of patients on statins; (C) the difference in LDL-C level in each country, relative to the UK: unadjusted (left-hand bar for each country), adjusted for age, gender, race, diabetes, hypertension and smoking (middle bar), and further adjusted for statin use (right-hand bar); (D) the relationship between the LDL-C target and the use of statins (S: statin use; NS: no statin use; OT: over-target for LDL-C; T: on-target for LDL-C).

FIGURE 4

Bicarbonate levels and the use of bicarbonate supplementation. (A) The percentage of on- or under-target patients; (B) the percentage of patients with bicarbonate supplementation; (C) the difference in bicarbonate level in each country, relative to the UK: unadjusted (the left-hand bar for each country), adjusted for age, gender, race, diabetes, hypertension and smoking (middle bar), or further adjusted for bicarbonate supplementation (right-hand bar); (D) the relationship between the target bicarbonate level and the use of bicarbonate supplementation (B: bicarbonate supplementation; NB: no bicarbonate supplementation; T: on-target for bicarbonate levels; BT: below-target for bicarbonate levels).

FIGURE 5

Phosphate levels and the use of phosphate binders. (A) The percentage of patients on- or over-target; (B) the number of phosphate binders; (C, D) the percentages of patients on non-calcium-based and calcium-based phosphate binders; (E) the difference in phosphate level in each country, relative to the UK, unadjusted (the left-hand bar for each country), adjusted for age, gender, race, diabetes, hypertension and smoking (middle bar), and further adjusted for phosphate binder use (right-hand bar); (F) the relationship between the target level and phosphate binder use (B: binder use; NB: no binder use; OT: over-target; T: on-target for phosphate levels; BT: below-target for phosphate levels).

FIGURE 6

PTH, 25-hydroxyvitamin D and calcium levels, and vitamin D and cinacalcet supplementation. (A–C) The percentage of patients on- or over-target for PTH, 25-OH vitamin D and calcium, respectively; (D–F) the difference in log-transformed PTH, 25-hydroxy vitamin D and calcium levels in each country, relative to the UK: unadjusted (the left-hand bar for each country), adjusted for age, gender, race, diabetes, hypertension and smoking (middle bar), and further adjusted for vitamin D and cinacalcet, vitamin D only, cinacalcet and calcium-based phosphate binders, respectively (right-hand bar); (G) the percentages of patients on cinacalcet.

FIGURE 7

Percentage of patients attaining various guidelines (blood pressure and levels of Hb, phosphate, PTH, calcium and bicarbonate) by country. The white segment indicates the proportion of patients on-target for 50% or more of the variables (including the proportion of patients meeting all the treatment targets), whereas the grey/hatched segments indicates the proportion of patients on-target for less than 50% of the variables (including the proportion of patients not meeting any of the treatment targets.