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. 2017 Mar 22:4:2054358117698668.
doi: 10.1177/2054358117698668. eCollection 2017.

Trends in the Management of Patients With Kidney Failure in Alberta, Canada (2004-2013)

Christy C Chong  1 , Helen Tam-Tham  1   2 , Brenda R Hemmelgarn  1   2   3   4 , Robert G Weaver  1   3 , Nairne Scott-Douglas  1   3   4   5 , Marcello Tonelli  1   2   3   4 , Robert R Quinn  1   2   3   4 , Liam Manns  1 , Braden J Manns  1   2   3   4
Affiliations

Trends in the Management of Patients With Kidney Failure in Alberta, Canada (2004-2013)

Christy C Chong et al. Can J Kidney Health Dis. .

Abstract
in English, French

Background: Based on clinical practice guidelines, specific quality indicators are examined to assess the performance of a health care system for patients with end-stage renal disease (ESRD). We examined trends in the proportion of patients with ESRD referred late to nephrology, timing of dialysis initiation in those with chronic kidney disease, and proportion of patients with ESRD treated with pre-emptive kidney transplantation or peritoneal dialysis (PD). Design:: This was a retrospective cohort study. Setting:: The study was conducted in Alberta, Canada. Patients:: Alberta residents aged 18 years or older with incident ESRD requiring renal replacement therapy between 2004 and 2013 were included. Measurements:: Descriptive statistics, and log binomial and linear regression models were used for analysis. Methods:: We determined the proportion of patients with ESRD who did not see a nephrologist within 90 days prior to starting dialysis (late referrals) and those who were receiving PD 90 days after dialysis initiation. Among those who had been seen by a nephrologist for at least 90 days, we also assessed the proportion who initiated dialysis with estimated glomerular filtration rate (eGFR) higher than or equal to 10.5 mL/min/1.73 m2, and underwent a pre-emptive transplant. Results:: Our cohort included 5343 patients (mean age 61.8 years, 61.2% male). Over a 10-year period, there was a decrease in the proportion of late referrals (26.4% to 21.1%, P = .001). We also noted a decrease in the proportion of dialysis initiation with eGFR higher than or equal to 10.5 mL/min/1.73 m2 (21.2% to 14.7%, P < .001), with a significant increase in the proportion of patients initiating dialysis as an inpatient (38.8% to 45.2%, P = .001). There was a non-significant decrease in both the proportion of patients treated with a pre-emptive transplant and PD at 90 days over the 10-year period. Limitations:: The use of administrative data restricted the availability of clinical data regarding underlying circumstances of each quality indicator, including patient symptoms, indications for dialysis initiation, and PD eligibility.

Conclusions: We noted improvement in late referrals and early dialysis initiation over time. However, we also noted low and stable use of pre-emptive kidney transplantation and PD at 90 days, which warrants further exploration. These findings support the need for quality improvement initiatives designed to address these gaps in care and improve outcomes for patients with kidney failure.

Mise en contexte: Les indicateurs de la qualité, lorsqu’ils s’appuient sur des preuves solides, permettent d’évaluer efficacement la performance d’un système de soins de santé, y compris les soins dispensés aux patients atteints d’insuffisance rénale terminale (IRT). Nous avons examiné les tendances en matière d’indicateurs de la qualité, y compris la proportion de patients orientés tardivement en néphrologie, ainsi que la proportion de patients traités par dialyse péritonéale (DP) ou au moyen d’une greffe de rein comme modalité initiale de remplacement de la fonction rénale.

Type d’étude: Il s’agit d’une étude de cohorte rétrospective.

Cadre: L’étude a été menée en Alberta, au Canada.

Patients: Il s’agit de patients albertains adultes nouvellement atteints d’IRT et nécessitant une thérapie continue de remplacement rénal.

Mesures: Nous avons mesuré la proportion de patients qui n’avait pas vu un néphrologue dans les 90 jours précédant l’amorce de la dialyse (orientation tardive) ; la proportion de patients chez qui on avait amorcé la dialyse à la suite d’une mesure du DFGe ≥ 10.5 mL/min/1.73 m2 et la proportion de patients qui avaient subi une greffe comme modalité initiale de thérapie de remplacement de la fonction rénale et la proportion de ceux qui étaient traités par DP à 90 jours.

Méthodologie: Nous avons utilisé des statistiques descriptives, un modèle logarithmique binomial ainsi que des modèles de régression linéaire pour évaluer les tendances des indicateurs de la qualité mentionnés ci-dessus.

Résultats: Notre cohorte était formée de 5343 patients (61,2 % d’hommes) dont l’âge moyen se situait à 61.8 ans. Sur une période de 10 ans, nous avons observé que la proportion d’orientations tardives est passée de 26.4% à 21.1% (P = .001). Nous avons aussi noté une diminution de la proportion de patients chez qui on avait amorcé la dialyse avec une mesure du DFGe ≥ 10.5 mL/min/1.73 m2 (21.2% à 14.7%, P < .001). Toutefois, nous avons constaté une augmentation significative de la proportion de patients chez qui la dialyse avait été amorcée lors d’une hospitalisation (38.8% à 45.2%, P = .001). Enfin, nous avons noté une diminution non significative dans la proportion de patients traités par une greffe comme modalité initiale de remplacement de la fonction rénale ainsi que dans la proportion des patients traités par DP à 90 jours au cours de la même période.

Limites de l’étude: L’utilisation de données administratives a limité la disponibilité des données cliniques en ce qui concerne les circonstances sous-jacentes à chaque indicateur de la qualité, incluant les symptômes du patient, les indications pour l’initiation de la dialyse et l’admissibilité à la dialyse péritonéale.

Conclusions: Nous avons constaté une amélioration en ce qui concerne les orientations tardives et l’initiation d’une dialyse précoce au fil du temps. Cependant, nous avons remarqué, de façon constante dans le temps, un faible recours à la transplantation rénale comme modalité initiale et à la DP à 90 jours, ce qui devrait faire l’objet d’une étude plus poussée. Ces constatations constituent la première étape d’une proposition pour l’amélioration de la qualité conçue pour réduire les écarts observés au niveau des soins, et visant à améliorer les résultats pour les patients atteints d’insuffisance rénale.

Keywords: chronic; health care; kidney failure; kidney transplantation; peritoneal dialysis; quality indicators; renal replacement therapy.

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Conflict of interest statement

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Figure 1.
Figure 1.
Participant flow diagram. aIdentified the earliest incident chronic dialysis or pre-emptive transplant record for each person in the NARP/SARP database who was 18 years or older at the time of the incident dialysis/transplant, and was present in the Alberta Health registry. NARP/SARP = Northern and Southern Alberta Renal Program.
Figure 2.
Figure 2.
Proportion of incident dialysis patients receiving PD at 90 days after dialysis initiation, by age group and 2-year periods. Note. Error bars show 95% confidence intervals. PD = peritoneal dialysis.
Figure 3.
Figure 3.
Proportion of patients who were referred late to a nephrologist, had a last eGFR greater than 10.5 mL/min/1.73 m2 before chronic dialysis initiation, were on PD 90 days after chronic dialysis initiation, and had a pre-emptive transplant among eligible patients. Note. eGFR = estimated glomerular filtration rate; PD = peritoneal dialysis.
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