Format

Send to

Choose Destination
Clin J Am Soc Nephrol. 2018 Dec 7;13(12):1842-1850. doi: 10.2215/CJN.03830318. Epub 2018 Nov 29.

Facility-Level Variations in Kidney Disease Care among Veterans with Diabetes and CKD.

Author information

1
Selzman Institute for Kidney Health, Section of Nephrology, sankar.navaneethan@bcm.edu.
2
Section of Nephrology.
3
Health Policy, Quality and Informatics Program, Health Services Research and Development Center for Innovations, and.
4
Section of Health Services Research, and.
5
Center for Longitudinal and Lifecourse Research, Faculty of Medicine, University of Queensland, Brisbane, Australia; and.
6
Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama.
7
Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.
8
Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas.
9
Selzman Institute for Kidney Health, Section of Nephrology.

Abstract

BACKGROUND AND OBJECTIVES:

Facility-level variation has been reported among veterans receiving care for various diseases. We studied the frequency and facility-level variations of guideline-recommended practices in patients with diabetes and CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS:

Patients with diabetes and concomitant CKD (eGFR 15-59 ml/min per 1.73 m2, measured twice, 90 days apart) receiving care in 130 facilities across the Veterans Affairs Health Care System were included (n=281,223). We studied the proportions of patients (facility-level) receiving recommended core measures and facility-level variations of these study outcomes using median rate ratios, adjusting for various patient and provider-level factors. Median rate ratio quantifies the degree to which care may vary for similar patients receiving care at two randomly chosen facilities, with <1 being no variation and >1.2 as substantial variation between the facilities. Study outcomes included measurement of urine albumin-to-creatinine ratio/urine protein-to-creatinine ratio and blood hemoglobin concentration, prescription of statins and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, BP<140/90 mm Hg, and referral to a Veterans Affairs nephrologist (only for those with eGFR<30 ml/min per 1.73 m2).

RESULTS:

Among those with eGFR 30-59 ml/min per 1.73 m2, proportion of patients receiving recommended core measures (median and interquartile range across facilities) were 37% (22%-47%) for urine albumin-to-creatinine ratio/urine protein-to-creatinine ratio, 74% (72%-79%) for hemoglobin measurement, 66% (62%-69%) for angiotensin-converting enzyme inhibitor/angiotensin receptor blocker prescription, 85% (74%-87%) for statin prescription, 47% (42%-53%) for achieving BP<140/90 mm Hg, and 13% (7%-16%) for meeting all outcome measures. Adjusted median rate ratios (95% confidence intervals) were 5.2 (4.1 to 6.4), 2.4 (2.1 to 2.6), 1.3 (1.2 to 1.3), 1.2 (1.2 to 1.3), 1.4 (1.3 to 1.4), and 4.1 (3.3 to 5.0), respectively. Median rate ratios were qualitatively similar in an analysis restricted to those with eGFR 15-29 ml/min per 1.73 m2.

CONCLUSIONS:

Among patients with diabetes and CKD, at facility-level, ordering of laboratory tests, and scheduling of nephrology referrals in eligible patients remains suboptimal, with substantial variations across facilities.

KEYWORDS:

Albumins; Angiotensin Receptor Antagonists; Angiotensin-Converting Enzyme Inhibitors; Confidence Intervals; Hemoglobins; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Kidney Function Tests; Outcome Assessment (Health Care); Referral and Consultation; Renal Insufficiency, Chronic; Veterans; blood pressure; chronic kidney disease, practice patterns, nephrology visits, variations, albuminuria, glomerular filtration rate; creatinine; diabetes mellitus

PMID:
30498000
DOI:
10.2215/CJN.03830318

Supplemental Content

Full text links

Icon for HighWire
Loading ...
Support Center