Facility-Level Variations in Kidney Disease Care among Veterans with Diabetes and CKD

Abstract

Background and objectives Facility-level variation has been reported among veterans receiving care for various diseases. We studied the frequency and facility-level variations of guideline-recommended practices in patients with diabetes and CKD. Design, setting, participants, & measurements Patients with diabetes and concomitant CKD (eGFR 15-59 ml/min per 1.73 m 2 , measured twice, 90 days apart) receiving care in 130 facilities across the Veterans Affairs Health Care System were included (n=281,223). We studied the proportions of patients (facility-level) receiving recommended core measures and facility-level variations of these study outcomes using median rate ratios, adjusting for various patient and provider-level factors. Median rate ratio quantifies the degree to which care may vary for similar patients receiving care at two randomly chosen facilities, with ,1 being no variation and .1.2 as substantial variation between the facilities. Study outcomes included measurement of urine albumin-to-creatinine ratio/ urine protein-to-creatinine ratio and blood hemoglobin concentration, prescription of statins and angiotensinconverting enzyme inhibitors/angiotensin receptor blockers, BP,140/90 mm Hg, and referral to a Veterans Affairs nephrologist (only for those with eGFR,30 ml/min per 1.73 m 2). Results Among those with eGFR 30-59 ml/min per 1.73 m 2 , proportion of patients receiving recommended core measures (median and interquartile range across facilities) were 37% (22%-47%) for urine albumin-to-creatinine ratio/urine protein-to-creatinine ratio, 74% (72%-79%) for hemoglobin measurement, 66% (62%-69%) for angiotensin-converting enzyme inhibitor/angiotensin receptor blocker prescription, 85% (74%-87%) for statin prescription, 47% (42%-53%) for achieving BP,140/90 mm Hg, and 13% (7%-16%) for meeting all outcome measures. Adjusted median rate ratios (95% confidence intervals) were 5.2 (4.1 to 6.4), 2.4 (2.1 to 2.6), 1.3 (1.2 to 1.3), 1.2 (1.2 to 1.3), 1.4 (1.3 to 1.4), and 4.1 (3.3 to 5.0), respectively. Median rate ratios were qualitatively similar in an analysis restricted to those with eGFR 15-29 ml/min per 1.73 m 2. Conclusions Among patients with diabetes and CKD, at facility-level, ordering of laboratory tests, and scheduling of nephrology referrals in eligible patients remains suboptimal, with substantial variations across facilities.

Chronic Kidney Disease Testing Among Primary Care Patients With Type 2 Diabetes Across 24 U.S. Health Care Organizations

“…Our findings of high eGFR and suboptimal uACR testing are consistent with previous studies (20)(21)(22)(23). While previous studies showed variation in CKD testing across facilities within the Veterans Affairs Health Care System and 11 primary care practices participating in a research network, our results quantify the substantial variation between and within a large national sample of health care organizations with >1,000 clinical practice sites (20,26).…”

Research Priorities for Kidney-Related Research—An Agenda to Advance Kidney Care: A Position Statement From the National Kidney Foundation

“…65 In a population receiving healthcare at Veterans Affairs Medical Centers, over 30% of patients with diabetes and CKD were not prescribed RAS inhibitors. 66 Statin medications also remain one of the few proven interventions to prevent incident cardiovascular events in adults with CKD not requiring KRT 67 , yet statin use is especially low (<30%) among adults with CKD in the absence of diabetes or known heart disease. 66,68,69 Studies are needed to increase the utilization of proven therapies, with specific emphasis on disadvantaged populations.…”

Facility-Level Variation in Dialysis Use and Mortality Among Older Veterans With Incident Kidney Failure

“…The degree of variation we observed for dialysis was similar to that found in more consensus-driven practices, such as the prescription of renin-angiotensin-aldosterone system blockers for adults with CKD and diabetes. 18 On the other hand, it is striking that the use of a life-sustaining treatment varies to a similar extent as the use of preventive treatments. Unexplained variation in dialysis use was more strongly associated with patient characteristics than facility characteristics, which could reflect strong institutional norms or unmeasured differences in clinician practices.…”