Monitoring and management of chronic kidney disease in ambulatory care - analysis of clinical and claims data from a population-based study

Abstract

Background: Although chronic kidney disease (CKD) is highly prevalent in the general population, little research has been conducted on CKD management in ambulatory care. Objective was to assess management and quality of care by evaluating CKD coding in ambulatory care, patient diagnosis awareness, frequency of monitoring and whether appropriate patients are referred to nephrology.

Methods: Clinical data from the population-based cohort Study of Health in Pomerania (SHIP-START) were matched with claims data of the Association of Statutory Health Insurance Physicians. Quality of care was evaluated according international and German recommendations.

Results: Data from 1778 participants (56% female, mean age 59 years) were analysed. 10% had eGFR < 60 ml/min/1.73m² (mean age 74 years), 15% had albuminuria. 21% had CKD as defined by KDIGO. 20% of these were coded and 7% self-reported having CKD. Coding increased with GFR stage (G3a 20%, G3b 61%, G4 75%, G5 100%). Serum creatinine and urinary dip stick testing were billed in the majority of all participants regardless of renal function. Testing frequency partially surpassed recommendations. Nephrology consultation was billed in few cases with stage G3b-G4.

Conclusion: CKD coding increased with stage and was performed reliably in stages ≥ G4, while CKD awareness was low. Adherence to monitoring and referral criteria varied, depending on the applicability of monitoring criteria. For assessing quality of care, consent on monitoring, patient education, referral criteria and coordination of care needs to be established, accounting for patient related factors, including age and comorbidity.

Trial registration: This study was prospectively registered as DRKS00009812 in the German Clinical Trials Register (DRKS).

Keywords: Ambulatory care; Chronic kidney disease; Management; Nephrology; Primary care.

Fig. 1

Flow chart of the study population. Data from the second follow-up of the Study of Health in Pomerania (SHIP-START-2) were analyzed. From the 2333 participants in SHIP-START-2, 1778 data sets were available for the analysis. *Of the excluded participants, some participants fulfilled more than one of the exclusion criteria

Fig. 2

Distribution of SHIP-START-2 participants according to KDIGO prognostic categorization [2]. Categories show the adjusted relative risk relating to 5 outcomes (all-cause mortality, cardiovascular mortality, kidney failure with dialysis, acute renal failure and CKD progression) based on a meta-analysis in the general population [25]. Green: low risk, yellow: moderate risk; orange: high risk; red: very high risk. Participants in the „low risk “ group can be classified as having normal kidney function. For 457 of the 1778 SHIP-START-2 participants in this study, albumin-creatinine ratios were not available. Thus, these participants were excluded for this visualization. Percentages indicate the respective fraction of the 1321 participants with available ACR included in this figure. ACR: albumin-creatinine ratio, GFR: Glomerular Filtration Rate, SHIP-START-2: second follow-up from the START cohort of the Study of Health In Pomerania