Patterns of Care for Patients with Chronic Kidney Disease in the United States

Abstract

Abstract. The burden of chronic kidney disease can be assessed by multiple criteria that underscore the need for improved detection, treatment, and outcome monitoring. Several process measures for the care of advanced CKD patients are examined herein. Twenty seven and 11% of patients with CKD in National Health and Nutrition Examination Surveys (NHANES) III had BP Ͻ140/90 and 130/85, respectively. In addition to inadequate prescription of antihypertensive drugs, another confounder is poor diagnostic recognition of CKD. Recent surveys of incident Medicare-eligible ESRD patients observed severe anemia in a preponderance of patients; mean and median hematocrit values were 27.7% Ϯ 5.9 and 27.8%, respectively. Only 23 to 28% of these patients were prescribed epoetin alfa. Clinical practice guidelines recommend that Ͻ10% of maintenance hemodialysis patients should be chronically dialyzed using percutaneous catheters. A recent national survey of vascular access types among incident American hemodialysis patients found that 30%, 41%, and 29% were dialyzing through a catheter, prosthetic graft, and autologous fistula, respectively. Tunneled catheters are associated with a 39% annual increased risk of death. Based on pharmacokinetic assumptions about the minimum amount of solute clearance by hemodialysis needed for patient survival in ESRD, a GFR of 10.5 ml/min per 1.73 m 2 is needed. The mean GFR of incident ESRD patients in the United States was 9.5 ml/min per 1.73 m 2 in 2000. In addition to the wide international variability in modality treatment selection, geographic variability exists within the United States; Ͻ7 to Ͼ15% of the prevalent patients are treated by peritoneal dialysis across the country. Despite survival and quality-of-life benefits with transplantation, most eligible recipients in the United States have not been placed on a transplant waiting list 6 mo after beginning dialysis. Last, Ͻ40% of incident ESRD patients in the United States have received the recommended frequency of mammography, PAP examinations, or prostatespecific antigen (PSA) or HbA1c measurements. These deficiencies in care for patients with advanced CKD likely adversely influence the survival of US ESRD patients. Contemporary outcome information supports this contention. CKD patients referred to a nephrologist for the first time within 90 d of the start of dialysis have an approximately 40% to 60% increased risk of death during their first year of renal replacement therapy (RRT). Thirty-five percent of CKD patients are seen within 90 d of receiving RRT. In addition, if fewer than five nephrology visits occur, death risks are increased by 15%. These findings confirm the urgent need for improvement in healthcare delivery for CKD patient in the United States.

Advanced Chronic Kidney Disease Practice Patterns among Nephrologists and Non-Nephrologists

“…Our findings support earlier research suggesting that nephrologists treat patients with advanced CKD more appropriately than do non-nephrologists (5,15,(21)(22)(23). However, our analysis demonstrates that there remains an opportunity for improvement in the care of these patients by nephrologists as well.…”

International Comparison of the Relationship of Chronic Kidney Disease Prevalence and ESRD Risk

“…slowing progression of CKD and development of ESRD (30,31). The quality of pre-ESRD care has been reported to be suboptimal in the United States (32,33), and several key markers of predialysis care in our study indicate differences between the two countries. Norwegian patients with CKD were referred earlier to a nephrologist and had more pre-ESRD visits.…”

The global epidemic of chronic kidney disease

“…(28) For a patient with CKD in the USA, the outcome was worse than for an equivalent patient with a diagnosis of colon or prostate cancer. (29) It was thought that differences in practice patterns could be responsible for these differences in outcomes. The Third National Health and Nutrition Examination Surveys (NHANES III) in the USA revealed that only 27% of patients with CKD had a blood pressure < 140/90 mmHg, and a majority of patients had severe anaemia (mean haematocrit 27.7%), with only one-quarter being prescribed erythropoietin despite insurance cover being available for most of them.…”