Fukuma Shingo, Ikenoue Tatsuyoshi, Shimizu Sayaka, Norton Edward C, Saran Rajiv, Yanagita Motoko, Kato Genta, Nakayama Takeo, Fukuhara Shunichi
Department of Human Health Sciences, Kyoto University Graduate School of Medicine.
Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine, Kyoto, Japan.
Med Care. 2020 Jul;58(7):625-631. doi: 10.1097/MLR.0000000000001301.
The quality of care received by a growing number of older patients with chronic kidney disease (CKD) has not been adequately examined.
The objective of this study was to assess the quality of CKD care among older patients and to clarify its association with the incidence of end-stage renal disease (ESRD).
This was a population-based cohort study.
Older (65 y and above) CKD patients diagnosed between October 2010 and September 2014 from the National Database of Health Insurance Claims of Japan.
A composite quality score (QS) of 3 quality measures for CKD care during the 6 months after CKD diagnosis was computed. The validated quality measures included urine testing for proteinuria, nutritional guidance, and nonsteroidal anti-inflammatory drugs avoidance. To assess the association between the QS and ESRD incidence, we used instrumental variable analysis after stratification for the history of diabetes.
Among the 890,773 older CKD patients, 2.9% progressed to ESRD (incidence rate of 12.5 per thousand person-years). In total, 59.9% underwent urine testing, 4.5% received nutritional guidance, and 91.2% avoided regular use of nonsteroidal anti-inflammatory drugs. An instrumental variable analysis revealed that a higher QS was associated with-lower ESRD incidence in patients diagnosed with diabetes (hazard ratio: 0.25, 95% confidence interval: 0.24-0.27 for each point higher score) but not in patients without a diagnosis of diabetes (hazard ratio: 0.99, 95% confidence interval: 0.92-1.05).
Among older CKD patients, quality of CKD care varied between patients, and better quality of CKD care was associated with a lower ESRD incidence in patients with diabetes but not in nondiabetic patients.
越来越多老年慢性肾脏病（CKD）患者所接受的医疗护理质量尚未得到充分研究。
本研究的目的是评估老年患者CKD护理质量，并阐明其与终末期肾病（ESRD）发病率的关联。
这是一项基于人群的队列研究。
2010年10月至2014年9月期间，从日本国民健康保险索赔数据库中确诊的65岁及以上老年CKD患者。
计算CKD诊断后6个月内CKD护理的3项质量指标的综合质量评分（QS）。经过验证的质量指标包括蛋白尿尿液检测、营养指导和避免使用非甾体抗炎药。为了评估QS与ESRD发病率之间的关联，我们在对糖尿病病史进行分层后使用了工具变量分析。
在890,773例老年CKD患者中，2.9%进展为ESRD（发病率为每千人年12.5例）。总体而言，59.9%的患者接受了尿液检测，4.5%的患者接受了营养指导，91.2%的患者避免定期使用非甾体抗炎药。工具变量分析显示，较高的QS与糖尿病确诊患者较低的ESRD发病率相关（风险比：0.25，95%置信区间：每高1分0.24 - 0.27），但与未确诊糖尿病的患者无关（风险比：0.99，95%置信区间：0.92 - 1.05）。
在老年CKD患者中，CKD护理质量因患者而异，更好的CKD护理质量与糖尿病患者较低的ESRD发病率相关，但与非糖尿病患者无关。
