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.
Department of Epidemiology and Biostatistics, University of California, San Francisco, CA.
Am J Kidney Dis. 2018 Aug;72(2):168-177. doi: 10.1053/j.ajkd.2018.01.058. Epub 2018 Apr 23.
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.
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.
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.
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.
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.
Potential misclassification of CKD; missing baseline medication data; limited to study of a public safety-net health care system.
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.
许多慢性肾脏病（CKD）患者未接受符合指南的治疗。我们研究了基于团队的初级保健 CKD 登记册对在公共安全网医疗服务系统中接受治疗的 CKD 患者的临床指标和护理过程的影响。
一项为期 1 年的 CKD 登记册与常规护理登记册的实用试验。
旧金山安全网初级保健环境中的初级保健提供者（PCP）及其 CKD 患者。
CKD 登记册在护理点识别所有 CKD 患者、血压（BP）>140/90mmHg 的患者、无血管紧张素转换酶（ACE）抑制剂/血管紧张素受体阻滞剂（ARB）处方的患者以及过去一年未进行白蛋白尿定量的患者。它还提供与这些指标相关的每季度反馈，以促进对 CKD 患者的“外展”。常规护理登记册提供护理点癌症筛查和免疫接种数据。
12 个月时收缩压的变化（主要结果）、血压控制患者的比例、ACE 抑制剂/ARB 处方、白蛋白尿定量、白蛋白尿严重程度和估计肾小球滤过率。
患者人群（n=746）的平均年龄为 56.7±12.1（标准差）岁，53%为女性，且具有多样性（8%非西班牙裔白人，35.7%黑人，24.5%西班牙裔和 24.4%亚洲人）。与常规护理登记册（49 名 PCP，461 名患者）相比，随机分配到 CKD 登记册（30 名 PCP，285 名患者）与 ACE 抑制剂/ARB 处方（调整后的 OR，2.25；95%CI，1.45-3.49）和白蛋白尿定量（调整后的 OR，2.44；95%CI，1.38-4.29）的两倍可能性更大。在 1 年的研究期间，随机分配到 CKD 登记册与收缩压、血压控制不佳的患者比例或白蛋白尿或估计肾小球滤过率无变化相关。
CKD 潜在的分类错误；基线药物数据缺失；仅限于公共安全网医疗保健系统的研究。
基于团队的安全网初级保健 CKD 登记册并未改善血压参数，但在 1 年后导致更多的白蛋白尿定量和更多的 ACE 抑制剂/ARB 处方。采用基于团队的 CKD 登记册可能是将 CKD 管理证据转化为实践的重要步骤。
