Samal Lipika, Wright Adam, Waikar Sushrut S, Linder Jeffrey A
Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont St., Boston, MA, 02120-1613, USA.
Harvard Medical School, Boston, MA, 02120, USA.
BMC Nephrol. 2015 Oct 12;16:162. doi: 10.1186/s12882-015-0154-x.
Primary care physicians (PCPs) typically manage early chronic kidney disease (CKD), but recent guidelines recommend nephrology co-management for some patients with stage 3 CKD and all patients with stage 4 CKD. We sought to compare quality of care for co-managed patients to solo managed patients.
We conducted a retrospective cross-sectional analysis. Patients included in the study were adults who visited a PCP during 2009 with laboratory evidence of CKD in the preceding two years, defined as two estimated glomerular filtration rates (eGFR) between 15-59 mL/min/1.73 m(2) separated by 90 days. We assessed process measures (serum eGFR test, urine protein/albumin test, angiotensin converting enzyme inhibitor or angiotensin receptor blocker [ACE/ARB] prescription, and several tests monitoring for complications) and intermediate clinical outcomes (mean blood pressure and blood pressure control) and performed subgroup analyses by CKD stage.
Of 3118 patients, 11 % were co-managed by a nephrologist. Co-management was associated with younger age (69 vs. 74 years), male gender (46 % vs. 34 %), minority race/ethnicity (black 32 % vs. 22 %; Hispanic 13 % vs. 8 %), hypertension (75 % vs. 66 %), diabetes (42 % vs. 26 %), and more PCP visits (5.0 vs. 3.9; p < 0.001 for all comparisons). After adjustment, co-management was associated with serum eGFR test (98 % vs. 94 %, p = <0.0001), urine protein/albumin test (82 % vs 36 %, p < 0.0001), and ACE/ARB prescription (77 % vs. 69 %, p = 0.03). Co-management was associated with monitoring for anemia and metabolic bone disease, but was not associated with lipid monitoring, differences in mean blood pressure (133/69 mmHg vs. 131/70 mmHg, p > 0.50) or blood pressure control. A subgroup analysis of Stage 4 CKD patients did not show a significant association between co-management and ACE/ARB prescription (80 % vs. 73 %, p = 0.26).
For stage 3 and 4 CKD patients, nephrology co-management was associated with increased stage-appropriate monitoring and ACE/ARB prescribing, but not improved blood pressure control.
基层医疗医生（PCP）通常负责管理早期慢性肾脏病（CKD），但最近的指南建议，对于部分3期CKD患者和所有4期CKD患者采用肾脏病共同管理模式。我们试图比较共同管理患者与单独管理患者的医疗质量。
我们进行了一项回顾性横断面分析。纳入研究的患者为2009年就诊于基层医疗医生且在前两年有CKD实验室证据的成年人，CKD定义为两次估算肾小球滤过率（eGFR）在15 - 59 mL/min/1.73 m²之间且间隔90天。我们评估了过程指标（血清eGFR检测、尿蛋白/白蛋白检测、血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂[ACE/ARB]处方以及多项并发症监测检测）和中间临床结局（平均血压和血压控制情况），并按CKD分期进行亚组分析。
在3118例患者中，11%由肾脏病医生共同管理。共同管理与患者年龄较轻（69岁对74岁）、男性（46%对34%）、少数族裔（黑人32%对22%；西班牙裔13%对8%）、高血压（75%对66%）、糖尿病（42%对26%）以及更多的基层医疗医生就诊次数（5.0次对3.9次；所有比较p < 0.001）相关。调整后，共同管理与血清eGFR检测（98%对94%，p = <0.0001）、尿蛋白/白蛋白检测（82%对36%，p < 0.0001）以及ACE/ARB处方（77%对69%，p = 0.03）相关。共同管理与贫血和代谢性骨病监测相关，但与血脂监测、平均血压差异（133/69 mmHg对131/70 mmHg，p > 0.50）或血压控制无关。对4期CKD患者的亚组分析未显示共同管理与ACE/ARB处方之间存在显著关联（80%对73%，p = 0.26）。
对于3期和4期CKD患者，肾脏病共同管理与增加适当分期的监测及ACE/ARB处方相关，但未改善血压控制。
