Samaan Farid, Vicente Cristiane Akemi, Pais Luiz Antônio Coutinho, Kirsztajn Gianna Mastroianni, Sesso Ricardo
Planning and Evaluation Group, State Department of Health of São Paulo, São Paulo 01246-901, Brazil.
Special Programs, Hapvida-NotreDame Intermédica Group, São Paulo 03164-140, Brazil.
Int J Nephrol. 2024 Oct 26;2024:5401633. doi: 10.1155/2024/5401633. eCollection 2024.
The objective of this study was to evaluate quality indicators of secondary health care in chronic kidney disease (CKD). This retrospective longitudinal study was conducted in an outpatient medical nephrology clinic of the Brazilian Unified Health System (UHS) and a multidisciplinary outpatient clinic of a private health plan (PHP). The inclusion criteria were age ≥ 18 years, ≥ 3 medical appointments, and follow-up time ≥ 6 months. Compared to PHP patients ( = 183), UHS patients ( = 276) were older (63.4 vs. 59.7 years, =0.04), had more arterial hypertension (AH) (91.7% vs. 84.7%, =0.02) and dyslipidemia (58.3 vs. 38.3%, < 0.01), and had a lower estimated baseline glomerular filtration rate (eGFR) (29.9 [21.5-42.0] vs. 39.1 [28.6-54.8] mL/min/1.73 m, < 0.01). Compared to PHP patients, UHS patients had a lower percentage of diabetics with glycated hemoglobin < 7.5% (46.1% vs. 61.2%, =0.03), fewer people with potassium < 5.5 mEq/L (90.4% vs. 95.6%, =0.04), and fewer referrals for hemodialysis with functioning arteriovenous fistula (AVF) (9.1% vs. 54.3%, < 0.01). The percentages of people with hypertension and blood pressure < 140 × 90 mmHg were similar between the UHS and PHP groups (59.7% vs. 66.7%; =0.17), as was the percentage of people with parathyroid hormone control (85.6% vs. 84.8%; =0.83), dyslipidemia and LDL-cholesterol < 100 mg/dL (38.3% vs. 49.3%; =0.13), phosphorus < 4.5 mg/dL (78.5% vs. 72.0%; =0.16), and 25-OH-vitamin-D > 30 ng/mL (28.4% vs. 36.5%; =0.11). The crude reduction in eGFR was greater in the UHS group than in PHP (2.3 [-0.1; 5.9] vs. 1.1 [-1.9; 4.6] mL/min/1.73 m; < 0.01). In the multivariate linear mixed-effects model, UHS patients also showed faster CKD progression over time than PHS ones (group effect, < 0.01; time effect, < 0.01; interaction, < 0.01). Quality of care for patients with CKD can be improved through both services, and multidisciplinary care may have a positive impact on the control of comorbidities, the progression of CKD, and the planning of the initiation of hemodialysis.
本研究的目的是评估慢性肾脏病（CKD）二级医疗保健的质量指标。这项回顾性纵向研究在巴西统一卫生系统（UHS）的门诊医学肾脏病诊所和一家私人健康计划（PHP）的多学科门诊诊所进行。纳入标准为年龄≥18岁、≥3次医疗预约以及随访时间≥6个月。与PHP患者（n = 183）相比，UHS患者（n = 276）年龄更大（63.4岁对59.7岁，P = 0.04），动脉高血压（AH）更多（91.7%对84.7%，P = 0.02），血脂异常更多（58.3%对38.3%，P < 0.01），且基线估计肾小球滤过率（eGFR）更低（29.9[21.5 - 42.0]对39.1[28.6 - 54.8]mL/min/1.73m²，P < 0.01）。与PHP患者相比，UHS患者糖化血红蛋白<7.5%的糖尿病患者比例更低（46.1%对61.2%，P = 0.03），血钾<5.5mEq/L的人数更少（90.4%对95.6%，P = 0.04），有功能动静脉内瘘（AVF）的血液透析转诊人数更少（9.1%对54.3%，P < 0.01）。UHS组和PHP组高血压且血压<140×90mmHg的患者比例相似（59.7%对66.7%；P = 0.17），甲状旁腺激素控制良好的患者比例也相似（85.6%对84.8%；P = 0.83），血脂异常且低密度脂蛋白胆固醇<100mg/dL的患者比例相似（38.3%对49.3%；P = 0.13），血磷<4.5mg/dL的患者比例相似（78.5%对72.0%；P = 0.16），25 - 羟基维生素D>30ng/mL的患者比例相似（28.4%对36.5%；P = 0.11）。UHS组eGFR的粗略下降幅度大于PHP组（2.3[-0.1；5.9]对1.1[-1.9；4.6]mL/min/1.73m²；P < 0.01）。在多变量线性混合效应模型中，UHS患者的CKD随时间进展也比PHS患者更快（组效应，P < 0.01；时间效应，P < 0.01；交互作用，P < 0.01）。通过这两种服务都可以改善CKD患者的医疗质量，多学科护理可能对合并症的控制、CKD的进展以及血液透析起始规划产生积极影响。
