Quality of Chronic Kidney Disease Management in Canadian Primary Care

Abstract

Importance: Although patients with chronic kidney disease (CKD) are routinely managed in primary care settings, no nationally representative study has assessed the quality of care received by these patients in Canada.

Objective: To evaluate the current state of CKD management in Canadian primary care practices to identify care gaps to guide development and implementation of national quality improvement initiatives.

Design, setting, and participants: This cross-sectional study leveraged Canadian Primary Care Sentinel Surveillance Network data from January 1, 2010, to December 31, 2015, to develop a cohort of 46 162 patients with CKD managed in primary care practices. Data analysis was performed from August 8, 2018, to July 31, 2019.

Main outcomes and measures: The study examined the proportion of patients with CKD who met a set of 12 quality indicators in 6 domains: (1) detection and recognition of CKD, (2) testing and monitoring of kidney function, (3) use of recommended medications, (4) monitoring after initiation of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs), (5) management of blood pressure, and (6) monitoring for glycemic control in those with diabetes and CKD. The study also analyzed associations of divergence from these quality indicators.

Results: The cohort comprised 46 162 patients (mean [SD] age, 69.2 [14.0] years; 25 855 [56.0%] female) with stage 3 to 5 CKD. Only 4 of 12 quality indicators were met by 75% or more of the study cohort. These indicators were receipt of an outpatient serum creatinine test within 18 months after confirmation of CKD, receipt of blood pressure measurement at any time during follow-up, achieving a target blood pressure of 140/90 mm Hg or lower, and receiving a hemoglobin A1c test for monitoring diabetes during follow-up. Indicators in the domains of detection and recognition of CKD, testing and monitoring of kidney function (specifically, urine albumin to creatinine ratio testing), use of recommended medications, and appropriate monitoring after initiation of treatment with ACEIs or ARBs were not met. Only 6529 patients (18.4%) with CKD received a urine albumin test within 6 months of CKD diagnosis, and 3954 (39.4%) had a second measurement within 6 months of an abnormal baseline urine albumin level. Older age (≥85 years) and CKD stage 5 were significantly associated with not satisfying the criteria for the quality indicators across all domains. Across age categories, younger patients (aged 18-49 years) and older patients (≥75 years) were less likely to be tested for albuminuria (314 of 1689 patients aged 18-49 years [18.5%], 1983 of 11 919 patients aged 75-84 years [61.6%], and 614 of 5237 patients aged ≥85 years [11.7%] received the urine albumin to creatinine ratio test within 6 months of initial estimated glomerular filtration rate <60 mL/min per 1.73 m2; P < .001). Patients aged 18 to 49 years were less commonly prescribed recommended medications (222 of 2881 [7.7%]), whereas patients aged 75 to 84 years were prescribed ACEIs or ARBs most frequently (2328 of 5262 [44.2%]; P < .001).

Conclusions and relevance: The findings suggest that management of CKD across primary care practices in Canada varies according to quality indicator. This study revealed potential priority areas for quality improvement initiatives in Canadian primary care practices.

Figure 1.. Development of the Chronic Kidney Disease (CKD) Cohort

The steps of developing a cohort of patients with CKD who were managed in primary care between January 1, 2010, and December 31, 2015, from Canadian Primary Care Sentinel Surveillance Network (CPCSSN) data repository are shown. Chronic kidney disease was defined as at least 2 estimated glomerular filtration rate (eGFR) measurements less than 60 mL/min per 1.73 m² at least 90 days apart.

Figure 2.. Decision Process for Identification of Individuals With Chronic Kidney Disease (CKD)

A sample timeline of the decision process followed to identify patients with CKD (defined as having ≥2 estimated glomerular filtration rate [eGFR] measurements <60 mL/min per 1.73 m² within at least 3 months but not more than 18 months) in the Canadian Primary Care Sentinel Surveillance Network data repository. Qualifying eGFR indicates an eGFR value less than 60 mL/min per 1.73 m²; blocked phase, period of 90 days after the first qualifying eGFR measurement at which no second eGFR measurement was considered confirmatory of CKD; qualifying phase, period of 3 to 18 months after the first qualifying eGFR measurement that a second eGFR measurement confirms CKD and qualifies the patient to be included in the study; and follow-up period, 1 year after confirmation of CKD to assess the use of appropriate medications.

Figure 3.. Overview of Quality of Care Indicators Studied

The 12 quality indicators for patients with chronic kidney disease (CKD) in primary care used in the study are shown. The 12 indicators were categories under the domains of detection and recognition of CKD, testing and monitoring of kidney function, use of recommended medications, monitoring after initiation of treatment with angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs), management of blood pressure, and monitoring for glycemic control. BP indicates blood pressure; eGFR, estimated glomerular filtration rate; HbA_1c, glycated hemoglobin; and UACR, urine albumin to creatinine ratio.