Philipneri Marie D, Rocca Rey Lisa A, Schnitzler Mark A, Abbott Kevin C, Brennan Daniel C, Takemoto Steven K, Buchanan Paula M, Burroughs Thomas E, Willoughby Lisa M, Lentine Krista L
Division of Nephrology, Saint Louis University School of Medicine, St Louis, MO 63104, USA.
Clin Exp Nephrol. 2008 Feb;12(1):41-52. doi: 10.1007/s10157-007-0016-3. Epub 2008 Jan 5.
Clinical practice guidelines for management of chronic kidney disease (CKD) have been developed within the Kidney Disease Outcomes Quality Initiative (K/DOQI). Adherence patterns may identify focus areas for quality improvement.
We retrospectively studied contemporary CKD care patterns within a private health system in the United States, and systematically reviewed literature of reported practices internationally. Five hundred and nineteen patients with moderate CKD (estimated GFR 30-59 ml/min) using healthcare benefits in 2002-2005 were identified from administrative insurance records. Thirty-three relevant publications in 2000-2006 describing care in 77,588 CKD patients were reviewed. Baseline demographic traits and provider specialty were considered as correlates of delivered care. Testing consistent with K/DOQI guidelines and prevalence of angiotensin converting enzyme inhibitor/angiotensin receptor blocker (ACEi/ARB) medication prescriptions were ascertained from billing claims. Care descriptions in the literature sample were based on medical charts, electronic records and/or claims.
KDOQI-consistent measurements of parathyroid hormone (7.1 vs. 0.6%, P = 0.0002), phosphorus (38.2 vs. 1.9%, P < 0.0001) and quantified urinary protein (23.8 vs. 9.4%, P = 0.008) were more common among CKD patients with versus without nephrology referral in the administrative data. Nephrology referral correlated with increased likelihood of testing for parathyroid hormone and phosphorus after adjustment for baseline patient factors. Use of ACEi/ARB medications was more common among patients with nephrology contact (50.0 vs. 30.0%; P = 0.008) but appeared largely driven by higher comorbidity burden. The literature review demonstrated similar practice patterns.
Delivery of CKD care may be monitored by administrative data. There is opportunity for improvement in CKD guideline adherence in practice.
慢性肾脏病（CKD）管理的临床实践指南已在肾脏病预后质量倡议（K/DOQI）中制定。依从模式可能确定质量改进的重点领域。
我们回顾性研究了美国一家私立医疗系统内当代CKD护理模式，并系统回顾了国际上报道的实践文献。从行政保险记录中识别出2002年至2005年使用医疗福利的519例中度CKD患者（估计肾小球滤过率为30 - 59 ml/分钟）。回顾了2000年至2006年期间描述77588例CKD患者护理情况的33篇相关出版物。基线人口统计学特征和医疗服务提供者专业被视为所提供护理的相关因素。从计费索赔中确定与K/DOQI指南一致的检测以及血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂（ACEi/ARB）药物处方的患病率。文献样本中的护理描述基于病历、电子记录和/或索赔。
在行政数据中，接受肾脏病转诊的CKD患者中，甲状旁腺激素（7.1%对0.6%，P = 0.0002）、磷（38.2%对1.9%，P < 0.0001）和定量尿蛋白（23.8%对9.4%，P = 0.008）的KDOQI一致测量更为常见。在调整基线患者因素后，肾脏病转诊与甲状旁腺激素和磷检测可能性增加相关。ACEi/ARB药物的使用在有肾脏病接触的患者中更常见（50.0%对30.0%；P = 0.008），但似乎很大程度上是由更高的合并症负担驱动的。文献综述显示了类似的实践模式。
CKD护理的提供可通过行政数据进行监测。在实践中，改善CKD指南依从性存在机会。
