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Selby NM, Taal MW. What every clinician needs to know about chronic kidney disease: Detection, classification and epidemiology. Diabetes Obes Metab 2024; 26 Suppl 6:3-12. [PMID: 38804058 DOI: 10.1111/dom.15683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 05/06/2024] [Accepted: 05/09/2024] [Indexed: 05/29/2024]
Abstract
Chronic kidney disease (CKD) is a major healthcare challenge, affecting >800 million people worldwide. Implications for population health result from the strong associations of CKD with increased rates of cardiovascular disease, heart failure, progressive CKD leading to kidney failure, acute kidney injury (AKI), and mortality. In addition to a single disease perspective, CKD commonly coexists alongside other long-term conditions, in particular type 2 diabetes and cardiovascular disease. CKD is therefore an important component of multimorbidity that influences individual management and impacts prognosis. CKD is defined by abnormalities of kidney structure or function of any cause with implications for health that are present for longer than 3 months. The diagnosis is usually made on the basis of an abnormal glomerular filtration rate (GFR < 60 mL/min/1.73 m2) and/or the presence of proteinuria (urine albumin to creatinine ratio > 30 mg/g or >3 mg/mmol). GFR is usually estimated from serum creatinine concentration using a variety of validated equations. However, serum creatinine is closely related to muscle mass and may therefore not be an accurate marker of GFR in people with high or low muscle mass (sarcopaenia). Cystatin C is an alternative endogenous marker of GFR that is increasingly being used but also has limitations. An estimate of GFR based on both creatinine and cystatin C is the most accurate. Diagnosis should be followed by classification and risk stratification to guide the development of a risk-based, personalized care plan. Improved detection and widespread implementation of optimal CKD management has the potential to bring major benefits to population health.
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Affiliation(s)
- Nicholas M Selby
- Centre for Kidney Research and Innovation, Academic Unit of Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
- Department of Renal Medicine, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Maarten W Taal
- Centre for Kidney Research and Innovation, Academic Unit of Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
- Department of Renal Medicine, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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Chandra M, Hertel M, Cahill S, Sakaguchi K, Khanna S, Mitra S, Luke J, Khau M, Mirabella J, Cropper A. Prevalence of Self-Reported Kidney Disease in Older Adults by Sexual Orientation: Behavioral Risk Factor Surveillance System Analysis (2014-2019). J Am Soc Nephrol 2023; 34:682-693. [PMID: 36735807 PMCID: PMC10103302 DOI: 10.1681/asn.0000000000000065] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 12/04/2022] [Indexed: 02/05/2023] Open
Abstract
SIGNIFICANCE STATEMENT Studies discusses CKD disparities by age, race and ethnicity, and socioeconomics. However, despite well-documented disparities in CKD risk factors in LGBT+ adults, limited literature addresses CKD prevalence in this population. This analysis uses Behavioral Risk Factor Surveillance System (2014-2019) data to compare self-reported kidney disease prevalence in LGBT+ older adults (older than 50 years) with their heterosexual peers. Our findings indicate that LGBT+ older adults have higher rates of self-reported kidney disease and a higher incidence of CKD risks including smoking, activity limitations, adverse health outcomes, and limited access to health care, housing, and employment. These results support increasing access to screening for CKD risk factors, providing culturally responsive health care, and addressing societal drivers of vulnerability in older LGBT+ adults. BACKGROUND Existing research documents disparities in CKD by age, race and ethnicity, and access to health care. However, research on CKD in lesbian, gay, bisexual, and trans (LGBT+) older adults, despite their higher rates of diabetes, heart disease, smoking, and alcohol use, is limited. METHODS Pooled data from the Behavioral Risk Factor Surveillance System (2014-2019) for 22,114 LGBT+ adults and 748,963 heterosexuals aged 50 and older were used to estimate the prevalence of self-reported kidney disease. Logistic regressions were used to compare older adults by sexual orientation. RESULTS Older LGBT+ men (adjusted odds ratio=1.3; 95% confidence interval [CI], 1.09-1.54) were more likely than their heterosexual counterparts to report kidney disease, after controlling for sociodemographic factors, health behaviors, access to health care, and self-reported coronary heart disease, HIV, and diabetes; LGBT+ men and women also reported higher incidences of known risk factors for CKD. For example, both LGBT+ men (odds ratio [OR]=1.39; [95% CI], 1.26-1.54) and LGBT+ women (OR=1.39; [95% CI], 1.25-1.55) were more likely to be smokers and have a higher incidence of activity limitations, adverse health outcomes, and limited access to health care, housing, and employment. CONCLUSION These results support increasing access to screenings for CKD risk factors, providing preventative education and culturally responsive and affirming care, and addressing other societal drivers of vulnerability in older LGBT+ adults. The findings also support the value of interventions that address the interaction between CKD risk factors and the social marginalization that older LGBT+ adults experience.
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Affiliation(s)
| | - Mollie Hertel
- NORC at the University of Chicago, Chicago, Illinois
| | | | | | - Saumya Khanna
- NORC at the University of Chicago, Chicago, Illinois
| | | | - Jordi Luke
- Office of Minority Health, Centers for Medicare & Medicaid Services, Baltimore, Maryland
| | - Meagan Khau
- Office of Minority Health, Centers for Medicare & Medicaid Services, Baltimore, Maryland
| | - Jack Mirabella
- Office of Minority Health, Centers for Medicare & Medicaid Services, Baltimore, Maryland
| | - Avareena Cropper
- Office of Minority Health, Centers for Medicare & Medicaid Services, Baltimore, Maryland
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Nee R, Yuan CM, Narva AS, Yan G, Norris KC. Overcoming barriers to implementing new guideline-directed therapies for chronic kidney disease. Nephrol Dial Transplant 2023; 38:532-541. [PMID: 36264305 PMCID: PMC9976771 DOI: 10.1093/ndt/gfac283] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Indexed: 11/13/2022] Open
Abstract
For the first time in many years, guideline-directed drug therapies have emerged that offer substantial cardiorenal benefits, improved quality of life and longevity in patients with chronic kidney disease (CKD) and type 2 diabetes. These treatment options include sodium-glucose cotransporter-2 inhibitors, nonsteroidal mineralocorticoid receptor antagonists and glucagon-like peptide-1 receptor agonists. However, despite compelling evidence from multiple clinical trials, their uptake has been slow in routine clinical practice, reminiscent of the historical evolution of angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker use. The delay in implementation of these evidence-based therapies highlights the many challenges to optimal CKD care, including: (i) clinical inertia; (ii) low CKD awareness; (iii) suboptimal kidney disease education among patients and providers; (iv) lack of patient and community engagement; (v) multimorbidity and polypharmacy; (vi) challenges in the primary care setting; (vii) fragmented CKD care; (viii) disparities in underserved populations; (ix) lack of public policy focused on health equity; and (x) high drug prices. These barriers to optimal cardiorenal outcomes can be ameliorated by a multifaceted approach, using the Chronic Care Model framework, to include patient and provider education, patient self-management programs, shared decision making, electronic clinical decision support tools, quality improvement initiatives, clear practice guidelines, multidisciplinary and collaborative care, provider accountability, and robust health information technology. It is incumbent on the global kidney community to take on a multidimensional perspective of CKD care by addressing patient-, community-, provider-, healthcare system- and policy-level barriers.
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Affiliation(s)
- Robert Nee
- Nephrology Service, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Department of Medicine, Uniformed Services University, Bethesda, MD, USA
| | - Christina M Yuan
- Nephrology Service, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Department of Medicine, Uniformed Services University, Bethesda, MD, USA
| | - Andrew S Narva
- College of Agriculture, Urban Sustainability and Environmental Studies, University of the District of Columbia, Washington, DC, USA
| | - Guofen Yan
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Keith C Norris
- Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
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Iroegbu C, Lewis L, Matura LA. An integrative review: Chronic kidney disease awareness and the social determinants of health inequities. J Adv Nurs 2021; 78:918-928. [PMID: 34910316 DOI: 10.1111/jan.15107] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 10/26/2021] [Accepted: 11/15/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chronic kidney disease is a common and prevalent condition in the United States. However, 90% of individuals with chronic kidney disease are unaware of their diagnosis. AIMS To summarize the empirical and theoretical literature to provide a comprehensive understanding of the social determinants of health inequities associated with CKD awareness. Social determinants of health inequities are underlying pathways that shape the health opportunities of individuals based on their social position. DESIGN Integrative review. DATA SOURCES (May 2020 through July 2020) Data sources included PubMed, sociological abstracts, ScienceDirect, CINAHL and Google Scholar. REVIEW METHODS Quantitative, qualitative and theoretical articles describing the association of social determinants of health inequities and chronic kidney disease awareness were included. RESULTS A total of 19 articles were reviewed: two qualitative, one theoretical and 16 quantitative. CONCLUSION Findings from this review revealed that socioeconomic status, education, race and gender are consistently associated with patient chronic kidney disease awareness. These findings should serve as a basis for further research on interventions to improve chronic kidney disease awareness as well as guide nurses and health care professionals in caring for this population.
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Affiliation(s)
- Christin Iroegbu
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lisa Lewis
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lea Ann Matura
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Chu CD, Chen MH, McCulloch CE, Powe NR, Estrella MM, Shlipak MG, Tuot DS. Patient Awareness of CKD: A Systematic Review and Meta-analysis of Patient-Oriented Questions and Study Setting. Kidney Med 2021; 3:576-585.e1. [PMID: 34401725 PMCID: PMC8350814 DOI: 10.1016/j.xkme.2021.03.014] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
RATIONALE & OBJECTIVE Patient awareness of disease is the first step toward effective management and disease control. Awareness of chronic kidney disease (CKD) has consistently been shown to be low, but studies estimating patient awareness of CKD have used different methods. We sought to determine whether the estimated prevalence of CKD awareness differed by the wording used to ascertain awareness or by setting characteristics. STUDY DESIGN Systematic review and meta-analysis. SETTING & STUDY POPULATIONS Adults with CKD not receiving dialysis. SELECTION CRITERIA FOR STUDIES We included studies that estimated CKD awareness, determined CKD status by laboratory criteria, and provided the exact question wording used to ascertain awareness. DATA EXTRACTION 2 reviewers independently extracted data for each study; discordance was resolved by a third independent reviewer. ANALYTICAL APPROACH Mixed-effects models were used to calculate pooled CKD awareness estimates and 95% CIs. RESULTS 32 studies were included. Publication year ranged from 2004 to 2017, with study populations ranging from 107 to 28,923 individuals. CKD awareness in individual studies ranged from 0.9% to 94.0%. Pooled CKD awareness was 19.2% (95% CI, 10.0%-33.6%) overall and was 26.5% (95% CI, 11.9%-48.9%) among individuals with an estimated glomerular filtration rate < 60 mL/min/1.73 m2. "Kidney problem" was the most sensitive question for CKD awareness (58.7%; 95% CI, 32.4%-80.8%); "weak or failing kidneys" was the least sensitive (12.3%; 95% CI, 4.5%-29.4%). CKD awareness was highest among patients from nephrology practices (86.2%; 95% CI, 74.9%-93.0%) and lowest in the general population (7.3%; 95% CI, 5.0%-10.5%). LIMITATIONS Significant heterogeneity across studies overall and among examined subgroups of wording and study setting. CONCLUSIONS Differently worded questions may lead to widely different estimates of CKD awareness. Consistent terminology is likely needed to most effectively surveil and leverage CKD awareness to improve management and disease control.
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Affiliation(s)
- Chi D. Chu
- Department of Medicine, University of California, San Francisco
| | - Michael H. Chen
- Minerva Schools at Keck Graduate Institute, San Francisco, CA
| | - Charles E. McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Neil R. Powe
- Department of Medicine, University of California, San Francisco
- Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California, San Francisco
- Center for Vulnerable Populations, University of California, San Francisco
| | - Michelle M. Estrella
- Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco
- Department of Medicine, San Francisco Veterans Affairs Health Care System, San Francisco, CA
| | - Michael G. Shlipak
- Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco
- Department of Medicine, San Francisco Veterans Affairs Health Care System, San Francisco, CA
| | - Delphine S. Tuot
- Department of Medicine, University of California, San Francisco
- Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California, San Francisco
- Center for Vulnerable Populations, University of California, San Francisco
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Jimenez EY, Kelley K, Schofield M, Brommage D, Steiber A, Abram JK, Kramer H. Medical Nutrition Therapy Access in CKD: A Cross-sectional Survey of Patients and Providers. Kidney Med 2021; 3:31-41.e1. [PMID: 33604538 PMCID: PMC7873758 DOI: 10.1016/j.xkme.2020.09.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
RATIONALE & OBJECTIVE Nutrition management can slow the progression of chronic kidney disease (CKD) and help manage complications of CKD, but few individuals with CKD receive medical nutrition therapy before initiating dialysis. This study aimed to identify knowledge, attitudes, experiences, and practices regarding medical nutrition therapy and barriers and facilitators to medical nutrition therapy access for individuals with CKD stages G1-G5 from the perspective of patients and providers. STUDY DESIGN Cross-sectional study composed of anonymous surveys. SETTING & POPULATION Adults with CKD stages G1-G5 and medical providers and registered dietitian nutritionists who regularly see patients with CKD stages G1-G5 were recruited by email using National Kidney Foundation and Academy of Nutrition and Dietetics databases and through the National Kidney Foundation 2019 Spring Clinical Meetings mobile app. ANALYTICAL APPROACH Descriptive analyses and Fisher exact tests were conducted with Stata SE 16. RESULTS Respondents included 348 patients, 66 registered dietitian nutritionists, and 30 medical providers. In general, patients and providers had positive perceptions of medical nutrition therapy and its potential to slow CKD progression and manage complications, and most patients reported interest in a medical nutrition therapy referral. However, there were feasibility concerns related to cost to the patient, lack of insurance coverage, and lack of renal registered dietitian nutritionists. There was low awareness of Medicare no-cost share coverage for medical nutrition therapy across patients and providers. About half the practices did not bill for medical nutrition therapy and those that did reported issues with being paid and low reimbursement rates. LIMITATIONS Results may not be generalizable due to the small number of respondents and the potential for self-selection, nonresponse, and social desirability bias. CONCLUSIONS Many patients with CKD stages G1-G5 are interested in medical nutrition therapy and confident that it can help with disease management, but there are feasibility concerns related to cost to the patient, insurance coverage, and reimbursement. There are significant opportunities to design and test interventions to facilitate medical nutrition therapy access for patients with CKD stages G1-G5.
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Affiliation(s)
- Elizabeth Yakes Jimenez
- Nutrition Research Network, Research, International, and Scientific Affairs, Academy of Nutrition and Dietetics, Chicago, IL
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM
- College of Population Health, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Kathryn Kelley
- Nutrition Research Network, Research, International, and Scientific Affairs, Academy of Nutrition and Dietetics, Chicago, IL
| | - Marsha Schofield
- Governance and Nutrition Services Coverage, Academy of Nutrition and Dietetics, Chicago, IL
| | | | - Alison Steiber
- Nutrition Research Network, Research, International, and Scientific Affairs, Academy of Nutrition and Dietetics, Chicago, IL
| | - Jenica K. Abram
- Nutrition Research Network, Research, International, and Scientific Affairs, Academy of Nutrition and Dietetics, Chicago, IL
| | - Holly Kramer
- Division of Nephrology and Hypertension, Department of Public Health Sciences and Medicine, Loyola University Medical Center, Maywood, IL
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Peralta CA, Livaudais-Toman J, Stebbins M, Lo L, Robinson A, Pathak S, Scherzer R, Karliner LS. Electronic Decision Support for Management of CKD in Primary Care: A Pragmatic Randomized Trial. Am J Kidney Dis 2020; 76:636-644. [PMID: 32682696 PMCID: PMC7606321 DOI: 10.1053/j.ajkd.2020.05.013] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 05/03/2020] [Indexed: 12/26/2022]
Abstract
RATIONALE & OBJECTIVE Most adults with chronic kidney disease (CKD) in the United States are cared for by primary care providers (PCPs). We evaluated the feasibility and preliminary effectiveness of an electronic clinical decision support system (eCDSS) within the electronic health record with or without pharmacist follow-up to improve the management of CKD in primary care. STUDY DESIGN Pragmatic cluster-randomized trial. SETTING & PARTICIPANTS 524 adults with confirmed creatinine-based estimated glomerular filtration rates of 30 to 59mL/min/1.73m2 cared for by 80 PCPs at the University of California San Francisco. Electronic health record data were used for patient identification, intervention deployment, and outcomes ascertainment. INTERVENTIONS Each PCP's eligible patients were randomly assigned as a group into 1 of 3 treatment arms: (1) usual care; (2) eCDSS: testing of creatinine, cystatin C, and urinary albumin-creatinine ratio with individually tailored guidance for PCPs on blood pressure, potassium, and proteinuria management, cardiovascular risk reduction, and patient education; or (3) eCDSS plus pharmacist counseling (eCDSS-PLUS). OUTCOMES The primary clinical outcome was change in blood pressure over 12 months. Secondary outcomes were PCP awareness of CKD and use of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and statin therapy. RESULTS All 80 eligible PCPs participated. Mean patient age was 70 years, 47% were nonwhite, and mean estimated glomerular filtration rate was 56±0.6mL/min/1.73m2. Among patients receiving eCDSS with or without pharmacist counseling (n=336), 178 (53%) completed laboratory measurements and 138 (41%) had laboratory measurements followed by a PCP visit with eCDSS deployment. eCDSS was opened by the PCP for 102 (74%) patients, with at least 1 suggested order signed for 83 of these 102 (81%). Changes in systolic blood pressure were-2.1±1.5mm Hg with usual care, -2.8±1.8mm Hg with eCDSS, and -1.1±1.1 with eCDSS-PLUS (P=0.7). PCP awareness of CKD was 16% with usual care, 26% with eCDSS, and 32% for eCDSS-PLUS (P=0.09). In as-treated analyses, PCP awareness of CKD was significantly greater with eCDSS and eCDSS-PLUS (73% and 69%) versus usual care (47%; P=0.002). LIMITATIONS Recruitment of smaller than intended sample size and limited uptake of the testing component of the intervention. CONCLUSIONS Although we were unable to demonstrate the effectiveness of eCDSS to lower blood pressure and uptake of the eCDSS was limited by low testing rates, eCDSS use was high when laboratory measurements were available and was associated with higher PCP awareness of CKD. FUNDING Grants from government (National Institutes of Health) and not-for-profit (American Heart Association) entities. TRIAL REGISTRATION Registered at ClinicalTrials.gov with study number NCT02925962.
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Affiliation(s)
- Carmen A Peralta
- Department of Medicine, University of California San Francisco, San Francisco, CA; The Kidney Health Research Collaborative, University of California San Francisco, San Francisco, CA; Cricket Health, Inc, San Francisco, CA.
| | - Jennifer Livaudais-Toman
- Department of Medicine, University of California San Francisco, San Francisco, CA; Multiethnic Health Equity Research Center, University of California San Francisco, San Francisco, CA
| | - Marilyn Stebbins
- Department of Clinical PharmacyUniversity of California San Francisco, San Francisco, CA
| | - Lowell Lo
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Andrew Robinson
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Sarita Pathak
- Department of Medicine, University of California San Francisco, San Francisco, CA; Multiethnic Health Equity Research Center, University of California San Francisco, San Francisco, CA
| | - Rebecca Scherzer
- Department of Medicine, University of California San Francisco, San Francisco, CA; The Kidney Health Research Collaborative, University of California San Francisco, San Francisco, CA
| | - Leah S Karliner
- Department of Medicine, University of California San Francisco, San Francisco, CA; Multiethnic Health Equity Research Center, University of California San Francisco, San Francisco, CA
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Luo L, Zhang M, Chen HF, Tang F, Fu LZ, Zhang DJ, Xia BQ, Dong CD, Xu YM, Wang LL, Lei N, Liu XS, Wu YF. Validity, reliability, and application of the electronic version of a chronic kidney disease patient awareness questionnaire: a pilot study. Postgrad Med 2020; 133:48-56. [PMID: 32758047 DOI: 10.1080/00325481.2020.1801029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVES A questionnaire which provides desirable reliability and validity has been previously developed to assess the disease awareness of diagnosed chronic kidney disease (CKD) patients. However, conventional paper questionnaires often have disadvantages, including recall bias. To substantially improve this, we therefore aimed to explore the feasibility of developing a smartphone-based electronic version (e-version) based upon its original paper version and subsequently tested its validity, reliability, and applicability. METHODS A pilot study was conducted at Guangdong Provincial Hospital of Chinese Medicine in Guangzhou, China, during August 2019. The e-version had identical content to the paper version and was adapted in terms of layout and assisted functions via the Wechat-incorporated Wen-Juan-Xing platform. Eligible patients with diagnosed CKD were invited to participate and were assigned the e-version. Randomly selected respondents received a test-retest of the same e-version 2 weeks after their first completion. In some instances, psychometric properties, including validity and reliability of the e-version, were examined. In others, its clinical application was also tested, which included comparisons among the clinical profiles of patients who had/had not responded to the questionnaire as well as patients with above or below average questionnaire scores. RESULTS Of the 225 patients screened, 217 were enrolled to participate, with a response rate of 52.5%. Desirable reliability (Cronbachα = 0.962, ICC for total scores = 0.948), while good convergent validity (Cronbachα = 0.962) and low discriminant validity (one extracted component), of the e-version were detected. Performing inter-group comparisons highlighted statistical differences in terms of higher education level (z = -2.436, P = 0.015) and earlier CKD stages (z = -1.978, P = 0.048), with these patients often preferring to respond. No significant differences were detected in the clinical profiles between respondents who obtained an above or below average questionnaire score. CONCLUSION The e-version is reliable but was not shown to be a valid approach. Audiences with higher education levels and less advanced disease condition may prefer to respond to the e-version. Adaptation of this e-questionnaire, from its original paper version, may not be a direct transition and meticulous modifications may be required during the transition process. TRIAL REGISTRATION Chinese Clinical Trial Registry (ChiCTR1900024633).
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Affiliation(s)
- Li Luo
- The Second Clinical College, Guangzhou University of Chinese Medicine , Guangzhou, China
| | - Min Zhang
- The Second Clinical College, Guangzhou University of Chinese Medicine , Guangzhou, China
| | - Hui-Fen Chen
- The Second Clinical College, Guangzhou University of Chinese Medicine , Guangzhou, China
| | - Fang Tang
- Chronic Disease Management Outpatient, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine) , Guangzhou, China
| | - Li-Zhe Fu
- Chronic Disease Management Outpatient, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine) , Guangzhou, China
| | - Ding-Jun Zhang
- The Second Clinical College, Guangzhou University of Chinese Medicine , Guangzhou, China
| | - Bing-Qing Xia
- The Second Clinical College, Guangzhou University of Chinese Medicine , Guangzhou, China
| | - Chen-Di Dong
- The Second Clinical College, Guangzhou University of Chinese Medicine , Guangzhou, China
| | - Yan-Min Xu
- The Second Clinical College, Guangzhou University of Chinese Medicine , Guangzhou, China
| | - Ling-Lan Wang
- The Second Clinical College, Guangzhou University of Chinese Medicine , Guangzhou, China
| | - Nuo Lei
- The Second Clinical College, Guangzhou University of Chinese Medicine , Guangzhou, China
| | - Xu-Sheng Liu
- Renal Division, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine) , Guangzhou, China
| | - Yi-Fan Wu
- Renal Division, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine) , Guangzhou, China
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Chu CD, McCulloch CE, Banerjee T, Pavkov ME, Burrows NR, Gillespie BW, Saran R, Shlipak MG, Powe NR, Tuot DS. CKD Awareness Among US Adults by Future Risk of Kidney Failure. Am J Kidney Dis 2020; 76:174-183. [PMID: 32305206 PMCID: PMC7387135 DOI: 10.1053/j.ajkd.2020.01.007] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 01/06/2020] [Indexed: 12/22/2022]
Abstract
RATIONALE & OBJECTIVE Persons with chronic kidney disease (CKD) are often unaware of their disease status. Efforts to improve CKD awareness may be most effective if focused on persons at highest risk for progression to kidney failure. STUDY DESIGN Serial cross-sectional surveys. SETTING & PARTICIPANTS Nonpregnant adults (aged≥20 years) with CKD glomerular filtration rate categories 3-4 (G3-G4) who participated in the National Health and Nutrition Examination Survey from 1999 to 2016 (n = 3,713). PREDICTOR 5-year kidney failure risk, estimated using the Kidney Failure Risk Equation. Predicted risk was categorized as minimal (<2%), low (2%-<5%), intermediate (5%-<15%), or high (≥15%). OUTCOME CKD awareness, defined by answering "yes" to the question "Have you ever been told by a doctor or other health professional that you had weak or failing kidneys?" ANALYTICAL APPROACH Prevalence of CKD awareness was estimated within each risk group using complex sample survey methods. Associations between Kidney Failure Risk Equation risk and CKD awareness were assessed using multivariable logistic regression. CKD awareness was compared with awareness of hypertension and diabetes during the same period. RESULTS In 2011 to 2016, unadjusted CKD awareness was 9.6%, 22.6%, 44.7%, and 49.0% in the minimal-, low-, intermediate-, and high-risk groups, respectively. In adjusted analyses, these proportions did not change over time. Awareness of CKD, including among the highest risk group, remains consistently below that of hypertension and diabetes and awareness of these conditions increased over time. LIMITATIONS Imperfect sensitivity of the "weak or failing kidneys" question for ascertaining CKD awareness. CONCLUSIONS Among adults with CKD G3-G4 who have 5-year estimated risks for kidney failure of 5%-<15% and≥15%, approximately half were unaware of their kidney disease, a gap that has persisted nearly 2 decades.
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Affiliation(s)
- Chi D Chu
- Departments of Medicine, University of California San Francisco, San Francisco, CA.
| | - Charles E McCulloch
- Biostatistics and Epidemiology, University of California San Francisco, San Francisco, CA
| | - Tanushree Banerjee
- Departments of Medicine, University of California San Francisco, San Francisco, CA
| | - Meda E Pavkov
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Nilka R Burrows
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Brenda W Gillespie
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI
| | - Rajiv Saran
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Michael G Shlipak
- Kidney Health Research Collaborative, San Francisco Veterans Affairs Hospital, San Francisco, CA
| | - Neil R Powe
- Departments of Medicine, University of California San Francisco, San Francisco, CA; Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, San Francisco, CA
| | - Delphine S Tuot
- Departments of Medicine, University of California San Francisco, San Francisco, CA; Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, San Francisco, CA
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Litvin CB, Nietert PJ, Jenkins RG, Wessell AM, Nemeth LS, Ornstein SM. Translating CKD Research into Primary Care Practice: a Group-Randomized Study. J Gen Intern Med 2020; 35:1435-1443. [PMID: 31823314 PMCID: PMC7210359 DOI: 10.1007/s11606-019-05353-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 09/11/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) is common in the primary care setting. Early interventions may prevent progression of renal disease and reduce risk for cardiovascular complications, yet quality gaps have been documented. Successful approaches to improve identification and management of CKD in primary care are needed. OBJECTIVE To assess whether implementation of a primary care improvement model results in improved identification and management of CKD DESIGN: 18-month group-randomized study PARTICIPANTS: 21 primary care practices in 13 US states caring for 107,094 patients INTERVENTIONS: To promote implementation of CKD improvement strategies, intervention practices received clinical quality measure (CQM) reports at least quarterly, hosted an on-site visit and 2 webinars, and sent clinician/staff representatives to a "best practice" meeting. Control practices received CQM reports at least quarterly. MAIN MEASURES Changes in practice adherence to a set of 11 CKD CQMs KEY RESULTS: We observed significantly greater improvements among intervention practices for annual screening for albuminuria in patients with diabetes or hypertension (absolute change 22% in the intervention group vs. - 2.6% in the control group, p < 0.0001) and annual monitoring for albuminuria in patients with CKD (absolute change 21% in the intervention group vs. - 2.0% in the control group, p < 0.0001). Avoidance of NSAIDs in patients with CKD declined in both intervention and control groups, with a significantly greater decline in the control practices (absolute change - 5.0% in the intervention group vs. - 10% in the control group, p < 0.0001). There were no other significant changes found for the other CQMs. Variable implementation of CKD improvement strategies was noted across the intervention practices. CONCLUSIONS Implementation of a primary care improvement model designed to improve CKD identification and management resulted in significantly improved care on 3 out of 11 CQMs. Incomplete adoption of improvement strategies may have limited further improvement. Improving CKD identification and management likely requires a longer and more intensive intervention.
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Affiliation(s)
- Cara B Litvin
- Division of General Internal Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Paul J Nietert
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Ruth G Jenkins
- Department of Family Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Andrea M Wessell
- Department of Family Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Lynne S Nemeth
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Steven M Ornstein
- Department of Family Medicine, Medical University of South Carolina, Charleston, SC, USA
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11
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Tummalapalli SL, Vittinghoff E, Crews DC, Cushman M, Gutiérrez OM, Judd SE, Kramer HJ, Peralta CA, Tuot DS, Shlipak MG, Estrella MM. Chronic Kidney Disease Awareness and Longitudinal Health Outcomes: Results from the REasons for Geographic And Racial Differences in Stroke Study. Am J Nephrol 2020; 51:463-472. [PMID: 32349001 PMCID: PMC7448609 DOI: 10.1159/000507774] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 04/06/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND The majority of people with chronic kidney disease (CKD) are unaware of their kidney disease. Assessing the clinical significance of increasing CKD awareness has critical public health and healthcare delivery implications. Whether CKD awareness among persons with CKD is associated with longitudinal health behaviors, disease management, and health outcomes is unknown. METHODS We analyzed data from participants with CKD in the REasons for Geographic And Racial Differences in Stroke study, a national, longitudinal, population-based cohort. Our predictor was participant CKD awareness. Outcomes were (1) health behaviors (smoking avoidance, exercise, and nonsteroidal anti-inflammatory drug use); (2) CKD management indicators (angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use, statin use, systolic blood pressure, fasting blood glucose, and body mass index); (3) change in estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR); and (4) health outcomes (incident end-stage kidney disease [ESKD], coronary heart disease [CHD], stroke, and death). Logistic and linear regressions were used to examine the association of baseline CKD awareness with outcomes of interest, adjusted for CKD stage and participant demographic and clinical factors. RESULTS Of 6,529 participants with baseline CKD, 285 (4.4%) were aware of their CKD. Among the 3,586 participants who survived until follow-up (median 9.5 years), baseline awareness was not associated with subsequent odds of health behaviors, CKD management indicators, or changes in eGFR and UACR in adjusted analyses. Baseline CKD awareness was associated with increased risk of ESKD (adjusted hazard ratio [aHR] 1.44; 95% CI 1.08-1.92) and death (aHR 1.18; 95% CI 1.00-1.39), but not with subsequent CHD or stroke, in adjusted models. CONCLUSIONS Individuals aware of their CKD were more likely to experience ESKD and death, suggesting that CKD awareness reflects disease severity. Most persons with CKD, including those that are high-risk, remain unaware of their CKD. There was no evidence of associations between baseline CKD awareness and longitudinal health behaviors, CKD management indicators, or eGFR decline and albuminuria.
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Affiliation(s)
- Sri Lekha Tummalapalli
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California, USA,
- Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco, California, USA,
- San Francisco Veterans Affairs Health Care System San Francisco, San Francisco, California, USA,
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Deidra C Crews
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
- Johns Hopkins Center for Health Equity, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mary Cushman
- Departments of Medicine and Pathology and Laboratory Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Orlando M Gutiérrez
- Department of Epidemiology, Birmingham, Alabama, USA
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Suzanne E Judd
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Holly J Kramer
- Department of Public Health Sciences and Medicine, Chicago, Illinois, USA
- Division of Nephrology and Hypertension, Loyola University, Chicago, Illinois, USA
| | - Carmen A Peralta
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California, USA
- Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco, California, USA
- San Francisco Veterans Affairs Health Care System San Francisco, San Francisco, California, USA
- Cricket Health, Inc., San Francisco, California, USA
| | - Delphine S Tuot
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California, USA
- Center for Innovation in Access and Quality at Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, California, USA
- Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, University of California, San Francisco, California, USA
| | - Michael G Shlipak
- Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco, California, USA
- San Francisco Veterans Affairs Health Care System San Francisco, San Francisco, California, USA
- Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Michelle M Estrella
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California, USA
- Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco, California, USA
- San Francisco Veterans Affairs Health Care System San Francisco, San Francisco, California, USA
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12
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Kurani S, Jeffery MM, Thorsteinsdottir B, Hickson LJ, Barreto EF, Haag J, Giblon R, Shah ND, McCoy RG. Use of Potentially Nephrotoxic Medications by U.S. Adults with Chronic Kidney Disease: NHANES, 2011-2016. J Gen Intern Med 2020; 35:1092-1101. [PMID: 31792867 PMCID: PMC7174522 DOI: 10.1007/s11606-019-05557-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 10/22/2019] [Accepted: 11/11/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND People with chronic kidney disease (CKD) are at risk for adverse events and/or CKD progression with use of renally eliminated or nephrotoxic medications. OBJECTIVE To examine the prevalence of potentially inappropriate medication (PIM) use by U.S. adults by CKD stage and self-reported CKD awareness. DESIGN Cross-sectional analysis of National Health and Nutrition Examination Surveys, 2011-2016 PARTICIPANTS: Non-pregnant adults with stages 3a (eGFR 45-59 mL/min/1.73 m2), 3b (eGFR 30-44), or 4-5 (eGFR < 30) CKD, stratified as CKD-aware/unaware. MAIN MEASURES PIMs were identified on the basis of KDIGO guidelines, label information, and literature review. We calculated proportions using any and individual PIMs, assessing for differences over CKD awareness within each CKD stage. Analyses were adjusted for age, sex, race/ethnicity, education, comorbidities, and insurance type. KEY RESULTS Adjusted proportions of U.S. adults taking any PIM(s) exceeded 50% for all CKD stages and awareness categories, and were highest among CKD-unaware patients with stages 4-5 CKD: 66.6% (95% CI, 55.5-77.8). Proton pump inhibitors, opioids, metformin, sulfonylureas, and non-steroidal anti-inflammatory drugs (NSAIDs) were all used frequently across CKD stages. NSAIDs were used less frequently when CKD-aware by patients with stage 3a CKD (2.2% [95% CI, - 0.3 to 4.7] vs. 10.7% [95% CI, 7.6 to 13.8]) and stages 4-5 CKD (0.8% [95% CI, - 0.9 to 2.5] vs. 16.5% [95% CI, 4.0 to 29.0]). Metformin was used less frequently when CKD-aware by patients with stage 3b CKD (8.1% [95% CI, 0.3-15.9] vs. 26.5% [95% CI, 17.4-35.7]) and stages 4-5 CKD (none vs. 20.8% [95% CI, 1.8-39.8]). The impact of CKD awareness was statistically significant after correction for multiple comparisons only for NSAIDs in stage 3a CKD. CONCLUSIONS PIMs are frequently used by people with CKD, with some impact of CKD awareness on NSAID and metformin use. This may lead to adverse outcomes or hasten CKD progression, reinforcing the need for improved medication management among people with CKD.
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Affiliation(s)
- Shaheen Kurani
- Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, MN, USA
| | - Molly Moore Jeffery
- Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Bjorg Thorsteinsdottir
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, First Street SW, Rochester, MN, USA
| | - LaTonya J Hickson
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Erin F Barreto
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - Jordan Haag
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - Rachel Giblon
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Nilay D Shah
- Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Rozalina G McCoy
- Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA.
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, First Street SW, Rochester, MN, USA.
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Ostropolets A, Reich C, Ryan P, Shang N, Hripcsak G, Weng C. Adapting electronic health records-derived phenotypes to claims data: Lessons learned in using limited clinical data for phenotyping. J Biomed Inform 2020; 102:103363. [PMID: 31866433 PMCID: PMC7390483 DOI: 10.1016/j.jbi.2019.103363] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/20/2019] [Accepted: 12/17/2019] [Indexed: 11/23/2022]
Abstract
Algorithms for identifying patients of interest from observational data must address missing and inaccurate data and are desired to achieve comparable performance on both administrative claims and electronic health records data. However, administrative claims data do not contain the necessary information to develop accurate algorithms for disorders that require laboratory results, and this omission can result in insensitive diagnostic code-based algorithms. In this paper, we tested our assertion that the performance of a diagnosis code-based algorithm for chronic kidney disorder (CKD) can be improved by adding other codes indirectly related to CKD (e.g., codes for dialysis, kidney transplant, suspicious kidney disorders). Following the best practices from Observational Health Data Sciences and Informatics (OHDSI), we adapted an electronic health record-based gold standard algorithm for CKD and then created algorithms that can be executed on administrative claims data and account for related data quality issues. We externally validated our algorithms on four electronic health record datasets in the OHDSI network. Compared to the algorithm that uses CKD diagnostic codes only, positive predictive value of the algorithms that use additional codes was slightly increased (47.4% vs. 47.9-48.5% respectively). The algorithms adapted from the gold standard algorithm can be used to infer chronic kidney disorder based on administrative claims data. We succeeded in improving the generalizability and consistency of the CKD phenotypes by using data and vocabulary standardized across the OHDSI network, although performance variability across datasets remains. We showed that identifying and addressing coding and data heterogeneity can improve the performance of the algorithms.
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Affiliation(s)
- Anna Ostropolets
- Columbia University Medical Center, New York, NY, USA; Observational Health Data Sciences and Informatics (OHDSI), New York, NY, USA
| | - Christian Reich
- IQVIA, Cambridge, MA, USA; Observational Health Data Sciences and Informatics (OHDSI), New York, NY, USA
| | - Patrick Ryan
- Janssen Research & Development, Raritan, NJ, USA; Observational Health Data Sciences and Informatics (OHDSI), New York, NY, USA
| | - Ning Shang
- Columbia University Medical Center, New York, NY, USA; Observational Health Data Sciences and Informatics (OHDSI), New York, NY, USA
| | - George Hripcsak
- Columbia University Medical Center, New York, NY, USA; Observational Health Data Sciences and Informatics (OHDSI), New York, NY, USA.
| | - Chunhua Weng
- Columbia University Medical Center, New York, NY, USA; Observational Health Data Sciences and Informatics (OHDSI), New York, NY, USA.
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14
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Tuot DS, Wong KK, Velasquez A, Crews DC, Zonderman AB, Evans MK, Powe NR. CKD Awareness in the General Population: Performance of CKD-Specific Questions. Kidney Med 2019; 1:43-50. [PMID: 32734184 PMCID: PMC7380399 DOI: 10.1016/j.xkme.2019.01.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Rationale & Objective Data from patients in one delivery system have suggested that the prevalence of chronic kidney disease (CKD) awareness differs by how the question is asked. We examined the sensitivity and specificity of different CKD awareness questions among diverse community-dwelling adults who were not necessarily engaged in primary care to determine the generalizability of prior results. Study Design Cross-sectional study. Setting & Participants Participants in the Healthy Aging in Neighborhoods of Diversity Across the Life Span (HANDLS) Study. Predictor CKD awareness, ascertained using 5 different questions. Outcome Sensitivity and specificity of each awareness question, using laboratory results as the gold standard. Analytic Approach Logistic regression was used to compare sensitivities of different awareness questions. Results Among 2,046 participants, mean (SD) age was 56.5 (9.1) years, 41.5% were men, and 61.3% were African American. More than 40% were poor, 35% reported not having health insurance, and 16.9% had low health literacy. More than 20% (n = 424) had CKD. Sensitivities of single CKD awareness questions ranged from 2.2% for “kidney damage” to 5.2% for “kidney problem.” Sensitivity of the compound question asking about “weak kidneys, failing kidneys, or kidney disease” was 19.5%. Sensitivity of this compound CKD awareness question was higher among study participants with more advanced CKD and low health literacy, and those who lived below the poverty level. Limitations Single measures of estimated glomerular filtration rate and albuminuria; study participants may have been more engaged in their health care than the average US adult, potentially limiting the generalizability of results. Conclusions CKD awareness is low among community-dwelling adults with kidney disease, though data using a sensitive compound question ascertaining awareness suggest that we have met the Healthy People 2020 goal related to CKD awareness of 13.4%. Understanding the phrases about kidney disease that are most understandable to patients with and at risk for CKD is important to further increase CKD awareness.
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Affiliation(s)
- Delphine S. Tuot
- Division of Nephrology, University of California, San Francisco
- Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco
- Address for Correspondence: Delphine S. Tuot, MDCM, MAS, Division of Nephrology, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, 1001 Potrero Ave, Bldg 100, Rm 342, San Francisco, CA 94110.
| | - Karen K. Wong
- Touro University California College of Osteopathic Medicine, Vallejo, CA
| | - Alexandra Velasquez
- Division of Nephrology, University of California, San Francisco
- Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco
| | - Deidra C. Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine
| | - Alan B. Zonderman
- National Institute on Aging, National Institutes of Health, Baltimore, MD
| | - Michele K. Evans
- National Institute on Aging, National Institutes of Health, Baltimore, MD
| | - Neil R. Powe
- Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco
- Department of Medicine, University of California, San Francisco, San Francisco, CA
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15
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Tuot DS, McCulloch CE, Velasquez A, Schillinger D, Hsu CY, Handley M, Powe NR. Impact of a Primary Care CKD Registry in a US Public Safety-Net Health Care Delivery System: A Pragmatic Randomized Trial. Am J Kidney Dis 2018; 72:168-177. [PMID: 29699885 DOI: 10.1053/j.ajkd.2018.01.058] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 01/22/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Many individuals with chronic kidney disease (CKD) do not receive guideline-concordant care. We examined the impact of a team-based primary care CKD registry on clinical measures and processes of care among patients with CKD cared for in a public safety-net health care delivery system. STUDY DESIGN Pragmatic trial of a CKD registry versus a usual-care registry for 1 year. SETTING & PARTICIPANTS Primary care providers (PCPs) and their patients with CKD in a safety-net primary care setting in San Francisco. INTERVENTION The CKD registry identified at point of care all patients with CKD, those with blood pressure (BP)>140/90mmHg, those without angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB) prescription, and those without albuminuria quantification in the past year. It also provided quarterly feedback pertinent to these metrics to promote "outreach" to patients with CKD. The usual-care registry provided point-of-care cancer screening and immunization data. OUTCOMES Changes in systolic BP at 12 months (primary outcome), proportion of patients with BP control, prescription of ACE inhibitors/ARBs, quantification of albuminuria, severity of albuminuria, and estimated glomerular filtration rate. RESULTS The patient population (n=746) had a mean age of 56.7±12.1 (standard deviation) years, was 53% women, and was diverse (8% non-Hispanic white, 35.7% black, 24.5% Hispanic, and 24.4% Asian). Randomization to the CKD registry (30 PCPs, 285 patients) versus the usual-care registry (49 PCPs, 461 patients) was associated with 2-fold greater odds of ACE inhibitor/ARB prescription (adjusted OR, 2.25; 95% CI, 1.45-3.49) and albuminuria quantification (adjusted OR, 2.44; 95% CI, 1.38-4.29) during the 1-year study period. Randomization to the CKD registry was not associated with changes in systolic BP, proportion of patients with uncontrolled BP, or degree of albuminuria or estimated glomerular filtration rate. LIMITATIONS Potential misclassification of CKD; missing baseline medication data; limited to study of a public safety-net health care system. CONCLUSIONS A team-based safety-net primary care CKD registry did not improve BP parameters, but led to greater albuminuria quantification and more ACE inhibitor/ARB prescriptions after 1 year. Adoption of team-based CKD registries may represent an important step in translating evidence into practice for CKD management.
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Affiliation(s)
- Delphine S Tuot
- Division of Nephrology, University of California, San Francisco, CA; Center for Vulnerable Populations at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA; Kidney Health Research Institute, University of California, San Francisco, San Francisco, CA.
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA
| | | | - Dean Schillinger
- Division of General Internal Medicine at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, San Francisco, CA; Center for Vulnerable Populations at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA
| | - Chi-Yuan Hsu
- Division of Nephrology, University of California, San Francisco, CA; Kidney Health Research Institute, University of California, San Francisco, San Francisco, CA
| | - Margaret Handley
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA; Division of General Internal Medicine at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, San Francisco, CA; Center for Vulnerable Populations at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA
| | - Neil R Powe
- Division of General Internal Medicine at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, San Francisco, CA; Center for Vulnerable Populations at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA
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16
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Devraj R, Borrego ME, Vilay AM, Pailden J, Horowitz B. Awareness, self-management behaviors, health literacy and kidney function relationships in specialty practice. World J Nephrol 2018; 7:41-50. [PMID: 29359119 PMCID: PMC5760511 DOI: 10.5527/wjn.v7.i1.41] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 11/20/2017] [Accepted: 12/04/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To determine the relationship between chronic kidney disease (CKD) awareness (CKD-A), self-management behaviors (CKD-SMB) knowledge, performance of CKD-SMBs, health literacy (HL) and kidney function.
METHODS Participants were eligible patients attending an outpatient nephrology clinic. Participants were administered: Newest Vital Sign to measure HL, CKD self-management knowledge tool (CKD-SMKT) to assess knowledge, past performance of CKD-SMB, CKD-A. Estimated GFR (eGFR) was determined using the MDRD-4 equation. Duration of clinic participation and CKD cause were extracted from medical charts.
RESULTS One-hundred-fifty patients participated in the study. eGFRs ranged from 17-152 mL/min per 1.73 m2. Majority (83%) of respondents had stage 3 or 4 CKD, low HL (63%), and were CKD aware (88%). Approximately 40% (10/25) of patients in stages 1 and 2 and 6.4% (8/125) in stages 3 and 4 were unaware of their CKD. CKD-A differed with stage (P < 0.001) but not by HL level, duration of clinic participation, or CKD cause. Majority of respondents (≥ 90%) correctly answered one or more CKD-SMKT items. Knowledge of one behavior, “controlling blood pressure” differed significantly by CKD-A. CKD-A was associated with past performance of two CKD-SMBs, “controlling blood pressure” (P = 0.02), and “keeping healthy body weight” (P = 0.01). Adjusted multivariate analyses between CKD-A and: (1) HL; and (2) CKD-SMB knowledge were non-significant. However, there was a significant relationship between CKD-A and kidney function after controlling for demographics, HL, and CKD-SMB (P < 0.05).
CONCLUSION CKD-A is not associated with HL, or better CKD-SMBs. CKD-A is significantly associated with kidney function and substantially lower eGFR, suggesting the need for focused patient education in CKD stages 1.
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Affiliation(s)
- Radhika Devraj
- School of Pharmacy, Southern Illinois University Edwardsville, Edwardsville, IL 62026, United States
| | - Matthew E Borrego
- College of Pharmacy, University of New Mexico, Albuquerque, NM 87131, United States
| | - A Mary Vilay
- College of Pharmacy, University of New Mexico, Albuquerque, NM 87131, United States
| | - Junvie Pailden
- College of Arts and Sciences, Southern Illinois University Edwardsville, Edwardsville, IL 62026, United States
| | - Bruce Horowitz
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, UT 84112, United States
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Dharmarajan SH, Bragg-Gresham JL, Morgenstern H, Gillespie BW, Li Y, Powe NR, Tuot DS, Banerjee T, Burrows NR, Rolka DB, Saydah SH, Saran R. State-Level Awareness of Chronic Kidney Disease in the U.S. Am J Prev Med 2017; 53:300-307. [PMID: 28410862 PMCID: PMC5706661 DOI: 10.1016/j.amepre.2017.02.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Revised: 02/01/2017] [Accepted: 02/15/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION This study examined state-level variation in chronic kidney disease (CKD) awareness using national estimates of disease awareness among adults in the U.S. with CKD. METHODS Data on U.S. adults were obtained from two national, population-based surveys: (1) the Behavioral Risk Factor Surveillance System (BRFSS 2011; n=506,467), a state-level phone survey containing information on self-reported kidney disease; and (2) the National Health and Nutrition Examination Survey (NHANES 2005-2012; n=20,831), containing physical health examination, surveys containing data on self-reported kidney disease, risk factors, and laboratory values. CKD was defined as an estimated glomerular filtration rate of 15-59 mL/minute/1.73 m2 or urinary albumin-to-creatinine ratio >30 mg/g. As BRFSS does not include laboratory data, CKD status for each person was imputed (multiple) based on a logistic regression model predicting NHANES CKD status. CKD awareness in each state was estimated as the weighted proportion of BRFSS participants with imputed CKD who reported having kidney disease. RESULTS Overall, estimated CKD awareness was 9.0% (95% CI=8.0%, 10.0%), ranging from 5.8% (95% CI=4.8%, 6.8%) in Iowa to 11.7% (95% CI=9.7%, 13.7%) in Arizona. Awareness was greater among adults with hypertension (12.0%) and diabetes (15.3%) than among adults without those conditions, and lower in Hispanics (6.0%) than in non-Hispanic whites (8.8%), non-Hispanic blacks (9.9%), and other racial/ethnic groups (12.7%). CONCLUSIONS Among individuals with CKD, awareness of their condition was very low and varied approximately twofold among states. This is the first study to estimate awareness of kidney disease by state for the U.S. adult population.
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Affiliation(s)
- Sai H Dharmarajan
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; Kidney Epidemiology and Cost Center, School of Public Health, University of Michigan, Ann Arbor, Michigan; Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Jennifer L Bragg-Gresham
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; Kidney Epidemiology and Cost Center, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Hal Morgenstern
- Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, Michigan; Department of Urology, Medical School, University of Michigan, Ann Arbor, Michigan; Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Brenda W Gillespie
- Kidney Epidemiology and Cost Center, School of Public Health, University of Michigan, Ann Arbor, Michigan; Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Yi Li
- Kidney Epidemiology and Cost Center, School of Public Health, University of Michigan, Ann Arbor, Michigan; Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Neil R Powe
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Delphine S Tuot
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Tanushree Banerjee
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Nilka Ríos Burrows
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Deborah B Rolka
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sharon H Saydah
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Rajiv Saran
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; Kidney Epidemiology and Cost Center, School of Public Health, University of Michigan, Ann Arbor, Michigan; Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan.
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Tuot DS, Boulware LE. Telehealth Applications to Enhance CKD Knowledge and Awareness Among Patients and Providers. Adv Chronic Kidney Dis 2017; 24:39-45. [PMID: 28224941 PMCID: PMC5324778 DOI: 10.1053/j.ackd.2016.11.017] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 11/21/2016] [Accepted: 11/22/2016] [Indexed: 12/31/2022]
Abstract
CKD affects 13% of the US adult population, causes excess mortality, and is associated with significant sociodemographic disparities. Optimal CKD management slows progression of disease and reduces cardiovascular-related outcomes. Resources for patients and primary care providers, major stakeholders in preventive CKD care, are critically needed to enhance understanding of the disease and to optimize CKD health, particularly because of the asymptomatic nature of kidney disease. Telehealth is defined as the use of electronic communication and telecommunications technology to support long-distance clinical health care, patient and professional health-related education, and public health and health administration. It provides new opportunities to enhance awareness and understanding among these important stakeholders. This review will examine the role of telehealth within existing educational theories, identify telehealth applications that can enhance CKD knowledge and behavior change among patients and primary care providers, and examine the advantages and disadvantages of telehealth vs usual modalities for education.
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Affiliation(s)
- Delphine S Tuot
- Division of Nephrology, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA; Center for Innovation in Access and Quality, University of California, San Francisco, San Francisco, CA; and Division of General Internal Medicine, Duke University School of Medicine, Durham, NC.
| | - L Ebony Boulware
- Division of Nephrology, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA; Center for Innovation in Access and Quality, University of California, San Francisco, San Francisco, CA; and Division of General Internal Medicine, Duke University School of Medicine, Durham, NC
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Tuot DS, Zhu Y, Velasquez A, Espinoza J, Mendez CD, Banerjee T, Hsu CY, Powe NR. Variation in Patients' Awareness of CKD according to How They Are Asked. Clin J Am Soc Nephrol 2016; 11:1566-1573. [PMID: 27340288 PMCID: PMC5012470 DOI: 10.2215/cjn.00490116] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 05/06/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVES Awareness of CKD is necessary for patient engagement and adherence to medical regimens. Having an accurate tool to assess awareness is important. Use of the National Health and Nutrition Examination Survey (NHANES) CKD awareness question "Have you ever been told by a doctor or other health professional that you had weak or failing kidneys (excluding kidney stones, bladder infections, or incontinence)?" produces surprisingly low measures of CKD awareness. We sought to compare the sensitivity and specificity of different questions ascertaining awareness of CKD and other health conditions. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Between August of 2011 and August of 2014, an in-person questionnaire was administered to 220 adults with CKD, diabetes, hypertension, or hyperlipidemia who received primary care in a public health care delivery system to ascertain awareness of each condition. CKD awareness was measured using the NHANES question, and other questions, asking if patients knew about their "kidney disease", "protein in the urine", "kidney problem", or "kidney damage." Demographic data were self-reported; health literacy was measured. The sensitivity and specificity of each question was calculated using the medical record as the gold standard. RESULTS In this diverse population (9.6% white, 40.6% black, 36.5% Hispanic, 12.3% Asian), the mean age was 58 years, 30% had a non-English language preference, and 45% had low health literacy. Eighty percent of participants had CKD, with a mean eGFR of 47.2 ml/min per 1.73 m(2). The sensitivities of each CKD awareness question were: 26.4% for "kidney damage", 27.7% for "kidney disease", 33.2% for "weak or failing kidneys", 39.8% for "protein in the urine", and 40.1% for "kidney problem." Specificities ranged from 82.2% to 97.6%. The best two-question combination yielded a sensitivity of 53.1% and a specificity of 83.3%. This was lower than awareness of hypertension (90.1%) or diabetes (91.8%). CONCLUSIONS CKD awareness is low compared with other chronic diseases regardless of how it is ascertained. Nevertheless, more sensitive questions to ascertain CKD awareness suggest current under-ascertainment.
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Affiliation(s)
| | - Yunnuo Zhu
- Center for Vulnerable Populations, and
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | | | | | | | - Tanushree Banerjee
- Center for Vulnerable Populations, and
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | | | - Neil R. Powe
- Center for Vulnerable Populations, and
- Department of Medicine, University of California, San Francisco, San Francisco, California
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Xie Y, Maziarz M, Tuot DS, Chertow GM, Himmelfarb J, Hall YN. Risk prediction to inform surveillance of chronic kidney disease in the US Healthcare Safety Net: a cohort study. BMC Nephrol 2016; 17:57. [PMID: 27276913 PMCID: PMC4898308 DOI: 10.1186/s12882-016-0272-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 06/01/2016] [Indexed: 01/13/2023] Open
Abstract
Background The capacity of electronic health record (EHR) data to guide targeted surveillance in chronic kidney disease (CKD) is unclear. We sought to leverage EHR data for predicting risk of progressing from CKD to end-stage renal disease (ESRD) to help inform surveillance of CKD among vulnerable patients from the healthcare safety-net. Methods We conducted a retrospective cohort study of adults (n = 28,779) with CKD who received care within 2 regional safety-net health systems during 1996–2009 in the Western United States. The primary outcomes were progression to ESRD and death as ascertained by linkage with United States Renal Data System and Social Security Administration Death Master files, respectively, through September 29, 2011. We evaluated the performance of 3 models which included demographic, comorbidity and laboratory data to predict progression of CKD to ESRD in conditions commonly targeted for disease management (hypertension, diabetes, chronic viral diseases and severe CKD) using traditional discriminatory criteria (AUC) and recent criteria intended to guide population health management strategies. Results Overall, 1730 persons progressed to end-stage renal disease and 7628 died during median follow-up of 6.6 years. Performance of risk models incorporating common EHR variables was highest in hypertension, intermediate in diabetes and chronic viral diseases, and lowest in severe CKD. Surveillance of persons who were in the highest quintile of ESRD risk yielded 83–94 %, 74–95 %, and 75–82 % of cases who progressed to ESRD among patients with hypertension, diabetes and chronic viral diseases, respectively. Similar surveillance yielded 42–71 % of ESRD cases among those with severe CKD. Discrimination in all conditions was universally high (AUC ≥0.80) when evaluated using traditional criteria. Conclusions Recently proposed discriminatory criteria account for varying risk distribution and when applied to common clinical conditions may help to inform surveillance of CKD in diverse populations. Electronic supplementary material The online version of this article (doi:10.1186/s12882-016-0272-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yuxiang Xie
- Kidney Research Institute, Department of Medicine, University of Washington, Seattle, WA, USA.,Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Marlena Maziarz
- Kidney Research Institute, Department of Medicine, University of Washington, Seattle, WA, USA.,Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Delphine S Tuot
- Division of Nephrology, University of California San Francisco and San Francisco General Hospital, San Francisco, CA, USA
| | - Glenn M Chertow
- Division of Nephrology, School of Medicine, Stanford University, Palo Alto, CA, USA
| | - Jonathan Himmelfarb
- Kidney Research Institute, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Yoshio N Hall
- Kidney Research Institute, Department of Medicine, University of Washington, Seattle, WA, USA. .,Kidney Research Institute, University of Washington, 325 9th Ave, Box 359606, Seattle, WA, 98104, USA.
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Tuot DS, Velasquez A, McCulloch CE, Banerjee T, Zhu Y, Hsu CY, Handley M, Schillinger D, Powe NR. The Kidney Awareness Registry and Education (KARE) study: protocol of a randomized controlled trial to enhance provider and patient engagement with chronic kidney disease. BMC Nephrol 2015; 16:166. [PMID: 26494562 PMCID: PMC4618520 DOI: 10.1186/s12882-015-0168-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 10/14/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is common and is associated with excess mortality and morbidity. Better management could slow progression of disease, prevent metabolic complications, and reduce cardiovascular outcomes. Low patient awareness of CKD and ineffective patient-provider communication can impede such efforts. We developed provider and patient-directed interventions that harness health information technology to enhance provider recognition of CKD and delivery of guideline concordant care and augment patient understanding and engagement in CKD care. METHODS/DESIGN We report the design and protocol of the Kidney Awareness Registry and Education (KARE) Study, a 2x2 factorial randomized controlled trial that examines the impact of a multi-level intervention on health outcomes among low-income English, Spanish and Cantonese-speaking patients with CKD in a safety net system. The intervention includes: (1) implementation of a primary care electronic CKD registry that notifies practice teams of patients' CKD status and employs a patient profile and quarterly feedback to encourage provision of guideline-concordant care at point-of-care and via outreach; and (2) a language-concordant, culturally-sensitive self-management support program that consists of automated telephone modules, provision of low-literacy written patient-educational materials and telephone health coaching. The primary outcomes of the trial are changes in systolic blood pressure (BP) and the proportion of patients with BP control (≤ 140/90 mmHg) after one year. Secondary outcomes include patient understanding of CKD, participation in healthy behaviors, and practice team delivery of guideline-concordant CKD care. DISCUSSION Results from the KARE study will provide data on the feasibility, effectiveness, and acceptability of technology-based interventions that support primary care efforts at improving health outcomes among vulnerable patients with CKD. TRIAL REGISTRATION ClinicalTrials.gov, number: NCT01530958.
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Affiliation(s)
- Delphine S Tuot
- Division of Nephrology, University of California, San Francisco, San Francisco, CA, 94143, USA.
- Center for Vulnerable Populations at San Francisco General Hospital, San Francisco, CA, USA.
- Renal Center at San Francisco General Hospital, 1001 Potrero Avenue Bldg 100, Room 342, San Francisco, CA, 94110, USA.
| | - Alexandra Velasquez
- Division of Nephrology, University of California, San Francisco, San Francisco, CA, 94143, USA.
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, 94143, USA.
| | - Tanushree Banerjee
- Division of General Internal Medicine at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94143, USA.
- Center for Vulnerable Populations at San Francisco General Hospital, San Francisco, CA, USA.
| | - Yunnuo Zhu
- Division of General Internal Medicine at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94143, USA.
| | - Chi-yuan Hsu
- Division of Nephrology, University of California, San Francisco, San Francisco, CA, 94143, USA.
| | - Margaret Handley
- Division of General Internal Medicine at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94143, USA.
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, 94143, USA.
| | - Dean Schillinger
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, 94143, USA.
- Center for Vulnerable Populations at San Francisco General Hospital, San Francisco, CA, USA.
| | - Neil R Powe
- Division of General Internal Medicine at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94143, USA.
- Center for Vulnerable Populations at San Francisco General Hospital, San Francisco, CA, USA.
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Brown B, Williams R, Sperrin M, Frank T, Ainsworth J, Buchan I. Making audit actionable: an example algorithm for blood pressure management in chronic kidney disease. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2014; 2014:343-52. [PMID: 25954337 PMCID: PMC4419945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Despite widespread use of clinical guidelines, actual care often falls short of ideal standards. Electronic health records (EHR) can be analyzed to provide information on how to improve care, but this is seldom done in sufficient detail to guide specific action. We developed an algorithm to provide practical, actionable information for care quality improvement using blood pressure (BP) management in chronic kidney disease (CKD) as an exemplar. We used UK clinical guidelines and EHR data from 440 patients in Salford (UK) to develop the algorithm. We then applied it to 532,409 individual patient records, identifying 11,097 CKD patients, 3,766 (34%) of which showed room for improvement in their care: either through medication optimization or better BP monitoring. Manual record reviews to evaluate accuracy indicated a positive-predictive value of 90%. Such algorithms could help improve the management of chronic conditions by providing the missing link between clinical audit and decision support.
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Affiliation(s)
- Benjamin Brown
- Centre for Health Informatics, University of Manchester, UK ; Greater Manchester Primary Care Patient Safety Translational Research Centre, University of Manchester, UK
| | - Richard Williams
- Centre for Health Informatics, University of Manchester, UK ; Greater Manchester Primary Care Patient Safety Translational Research Centre, University of Manchester, UK
| | - Matthew Sperrin
- Centre for Health Informatics, University of Manchester, UK ; Greater Manchester Primary Care Patient Safety Translational Research Centre, University of Manchester, UK
| | - Timothy Frank
- Centre for Health Informatics, University of Manchester, UK
| | - John Ainsworth
- Centre for Health Informatics, University of Manchester, UK ; Greater Manchester Primary Care Patient Safety Translational Research Centre, University of Manchester, UK
| | - Iain Buchan
- Centre for Health Informatics, University of Manchester, UK ; Greater Manchester Primary Care Patient Safety Translational Research Centre, University of Manchester, UK
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Matheny ME, Peterson JF, Eden SK, Hung AM, Speroff T, Abdel-Kader K, Parr SK, Ikizler TA, Siew ED. Laboratory test surveillance following acute kidney injury. PLoS One 2014; 9:e103746. [PMID: 25117447 PMCID: PMC4130516 DOI: 10.1371/journal.pone.0103746] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 07/01/2014] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Patients with hospitalized acute kidney injury (AKI) are at increased risk for accelerated loss of kidney function, morbidity, and mortality. We sought to inform efforts at improving post-AKI outcomes by describing the receipt of renal-specific laboratory test surveillance among a large high-risk cohort. METHODS We acquired clinical data from the Electronic health record (EHR) of 5 Veterans Affairs (VA) hospitals to identify patients hospitalized with AKI from January 1st, 2002 to December 31st, 2009, and followed these patients for 1 year or until death, enrollment in palliative care, or improvement in renal function to estimated GFR (eGFR) ≥ 60 L/min/1.73 m(2). Using demographic data, administrative codes, and laboratory test data, we evaluated the receipt and timing of outpatient testing for serum concentrations of creatinine and any as well as quantitative proteinuria recommended for CKD risk stratification. Additionally, we reported the rate of phosphorus and parathyroid hormone (PTH) monitoring recommended for chronic kidney disease (CKD) patients. RESULTS A total of 10,955 patients admitted with AKI were discharged with an eGFR<60 mL/min/1.73 m2. During outpatient follow-up at 90 and 365 days, respectively, creatinine was measured on 69% and 85% of patients, quantitative proteinuria was measured on 6% and 12% of patients, PTH or phosphorus was measured on 10% and 15% of patients. CONCLUSIONS Measurement of creatinine was common among all patients following AKI. However, patients with AKI were infrequently monitored with assessments of quantitative proteinuria or mineral metabolism disorder, even for patients with baseline kidney disease.
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Affiliation(s)
- Michael E. Matheny
- Geriatrics Research Education & Clinical Center (GRECC), Tennessee Valley Healthcare System (TVHS), Veteran's Health Administration, Nashville, TN, United States of America
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, United States of America
- Division of General Internal Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States of America
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - Josh F. Peterson
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, United States of America
- Division of General Internal Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - Svetlana K. Eden
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - Adriana M. Hung
- Geriatrics Research Education & Clinical Center (GRECC), Tennessee Valley Healthcare System (TVHS), Veteran's Health Administration, Nashville, TN, United States of America
- Division of Nephrology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - Theodore Speroff
- Geriatrics Research Education & Clinical Center (GRECC), Tennessee Valley Healthcare System (TVHS), Veteran's Health Administration, Nashville, TN, United States of America
- Division of General Internal Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States of America
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - Khaled Abdel-Kader
- Division of Nephrology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - Sharidan K. Parr
- Division of Nephrology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - T. Alp Ikizler
- Division of Nephrology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - Edward D. Siew
- Division of Nephrology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States of America
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Troidle L. The chronic kidney disease patient in the acute hospital environment. Adv Chronic Kidney Dis 2014; 21:355-9. [PMID: 24969387 DOI: 10.1053/j.ackd.2014.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 05/21/2014] [Accepted: 05/21/2014] [Indexed: 11/11/2022]
Abstract
CKD is common, affecting more than 10% of the adult US population. Hospital admissions are common among these patients and present challenges for their caregivers. In the acute hospital setting, there is often a lack of awareness of the CKD patient and the best practices developed to help this population. This can place the CKD patient at risk for medication errors such as incorrect dosage or administration of a potentially harmful or unhelpful medication. CKD patients may need procedures during a hospital stay that increase their risk of adverse events. Also, common admission practices such as placing intravenous access needs to be thoughtfully considered in this population.
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Abdel-Kader K, Greer RC, Boulware LE, Unruh ML. Primary care physicians' familiarity, beliefs, and perceived barriers to practice guidelines in non-diabetic CKD: a survey study. BMC Nephrol 2014; 15:64. [PMID: 24755164 PMCID: PMC4021215 DOI: 10.1186/1471-2369-15-64] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 04/16/2014] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Most non-dialysis dependent chronic kidney disease (CKD) patients are cared for by their primary care physicians (PCPs). Studies suggest many CKD patients receive suboptimal care. Recently, CKD clinical practice guidelines were updated with additional emphasis on albuminuria. METHODS We performed an internet-based, cross-sectional survey of active PCPs in the United States using the American Medical Association Physician Masterfile. We explored CKD guideline familiarity, self-reported practice behaviors, and attitudinal and external barriers to implementing guideline recommendations, including albuminuria testing. RESULTS Of 12,034 PCPs targeted, 848 opened a study email, 165 (19.5%) responded. Most respondents (88%) spent ≥50% of their time in clinical care. Respondents were generally in private practice (46%). Most PCPs (96%) felt that eGFR values were helpful. Approximately, 75% and 91% of PCPs reported testing for albuminuria in non-diabetic hypertensive patients with an eGFR > 60 ml/min/1.73 m2 and < 60 ml/min/1.73 m2, respectively. Barriers to albuminuria testing included a lack of effect on management, limited time, and the perceived absence of guidelines recommending testing. While PCPs expressed high levels of agreement with the definition of CKD, 30% were concerned with overdiagnosis in older adults with an eGFR in the CKD stage 3a range. Most PCPs felt that angiotensin converting enzyme inhibitor (ACEi)/ angiotensin II receptor blockers (ARBs) improved outcomes in CKD, though agreement was lower with severe vs. moderate albuminuria (78% vs. 85%, respectively, p = 0.03). Many PCPs (51%) reported being unfamiliar with CKD guidelines, but were receptive to systematic interventions to improve their CKD care. CONCLUSIONS PCPs generally agree with CKD clinical practice guidelines regarding CKD definition and albuminuria testing. However, future interventions are necessary to improve PCPs' familiarity with CKD guidelines, overcome barriers to albuminuria testing and, assist PCPs in targeting ACEi/ARBs to the patients most likely to benefit.
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Affiliation(s)
- Khaled Abdel-Kader
- Division of Nephrology and Hypertension, Vanderbilt University, 1161 21st Ave, S,, MCN S-3223, Nashville, TN 37232, USA.
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Cavanaugh KL, İkizler TA. Acknowledging Kidney Disease: Is Ignorance Salubrious? Am J Kidney Dis 2013; 61:536-9. [DOI: 10.1053/j.ajkd.2012.12.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 12/12/2012] [Indexed: 01/08/2023]
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Tuot DS, Plantinga LC, Judd SE, Muntner P, Hsu CY, Warnock DG, Gutiérrez OM, Safford M, Powe NR, McClellan WM. Healthy behaviors, risk factor control and awareness of chronic kidney disease. Am J Nephrol 2013; 37:135-43. [PMID: 23392070 DOI: 10.1159/000346712] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 12/22/2012] [Indexed: 12/27/2022]
Abstract
BACKGROUND/AIMS The association between chronic kidney disease (CKD) awareness and healthy behaviors is unknown. We examined whether CKD self-recognition is associated with healthy behaviors and achieving risk-reduction targets known to decrease risk of cardiovascular morbidity and CKD progression. METHODS CKD awareness, defined as a 'yes' response to 'Has a doctor or other health professional ever told you that you had kidney disease?', was examined among adults with CKD (eGFR <60 ml/min/1.73 m(2)) who participated in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. Odds of participation in healthy behaviors (tobacco avoidance, avoidance of regular nonsteroidal anti-inflammatory drug use, and physical activity) and achievement of risk-reduction targets (angiotensin-converting enzyme inhibitor/angiotensin receptor blocker use, systolic blood pressure control and glycemic control among those with diabetes) among those aware versus unaware of their CKD were determined by logistic regression, controlling for sociodemographics, access to care and comorbid conditions. Systolic blood pressure control was defined as <130 mm Hg (primary definition) or <140 mm Hg (secondary definition). RESULTS Of 2,615 participants, only 6% (n = 166) were aware of having CKD. Those who were aware had 82% higher odds of tobacco avoidance compared to those unaware (adjusted OR = 1.82, 95% CI 1.02-3.24). CKD awareness was not associated with other healthy behaviors or achievement of risk-reduction targets. CONCLUSIONS Awareness of CKD was only associated with participation in one healthy behavior and was not associated with achievement of risk-reduction targets. To encourage adoption of healthy behaviors, a better understanding of barriers to participation in CKD-healthy behaviors is needed.
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Affiliation(s)
- Delphine S Tuot
- Department of Medicine, University of California at San Francisco, San Francisco, CA 94110, USA.
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