Nurse Practitioner Care Compared with Primary Care or Nephrologist Care in Early CKD

Abstract

Background: Early interventions in chronic kidney disease (CKD) have been shown to improve health outcomes; however, gaps in access to nephrology care remain common. Nurse practitioners can improve access to care; however, the quality and outcomes of nurse practitioner care for CKD are uncertain. Methods: In this propensity score matched cohort study, patients with CKD meeting criteria for nurse practitioner care were matched 1:1 on their propensity scores for; 1) nurse practitioner care versus primary care alone, as well as 2) nurse practitioner versus nephrologist care. Processes of care were measured within one year following cohort entry, and clinical outcomes were measured over 5 years of follow-up and compared between propensity score matched groups. Results: 961 (99%) patients from the nurse practitioner clinic were matched on their propensity score to 961 (1%) patients receiving primary care only, while 969 (100%) patients from the nurse practitioner clinic were matched to 969 (7%) patients receiving nephrologist care. After matching to patients receiving primary care alone, those receiving nurse practitioner care had greater use of ACEi/ARB (82 versus 79%, absolute differences [AD] 3.4 [95% CI 0.0, 6.9]%) and statins (75 versus 66%, AD 9.7 [5.8, 13.6]%), fewer prescriptions of NSAIDS (10 versus 17%, AD –7.2 [-10.4, -4.2]%), greater eGFR and albuminuria monitoring, and lower rates of all-cause hospitalization (34.1 versus 43.3, rate difference -9.2 [-14.7, -3.8] per 100 person-years) and all-cause mortality (3.3 versus 6.0, rate difference -2.7 [-3.6, -1.7] per 100 person-years). When matched to patients receiving nephrologist care, those receiving nurse practitioner care were also more likely to be prescribed ACEi/ARBs and statins, with no difference in the risks of experiencing adverse clinical outcomes. Conclusions: Nurse practitioner care for patients with CKD was associated with better guideline-concordant care than primary care alone or nephrologist care, with clinical outcomes that were better than or equivalent to primary care alone, and similar to those with care by nephrologists.

Equity and Quality of Global Chronic Kidney Disease Care: What Are We Waiting for?

“…Nurse specialists, social workers, dieticians, and community health workers can be pivotal in screening, diagnosis, and management of CKD and its risk factors [100]. Guideline adherence and patient outcomes are often improved with nurse-compared with physiciandriven care [101]. This observation may result from many factors but requires further understanding to optimize care delivery overall.…”