A Decade After the KDOQI CKD Guidelines: Impact on Primary Care

Abstract

In many ways, chronic kidney disease (CKD) can be thought of as the chronic disease that gets no respect. Treatment and prevention of CKD is not part of any pay-for-performance incentives. Neither the American Board of Family Medicine nor the American Board of Internal Medicine has a Maintenance of Certification program to encourage practicing primary care physicians (PCPs) to learn more about improving CKD care. When the National Kidney Foundation (NKF) first published the KDOQI (Kidney Disease Outcomes Quality Initiative) guidelines,1National Kidney FoundationK/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: evaluation, classification, and stratification.Am J Kidney Dis. 2002; 39(2): S1-S266Google Scholar the attitude of many PCPs could be expressed as, “So what, I treat hypertension and diabetes, I just send patients to a nephrologist when they need dialysis.” By the same token, the attitude of some nephrologists was that early referral was the most important role of the PCP in CKD care. As shown in a study by Boulware et al,2Boulware L.E. Troll M.U. Jaar B.G. Myers D.I. Powe N.R. Identification and referral of patients with progressive CKD: a national study.Am J Kidney Dis. 2006; 48: 192-204Abstract Full Text Full Text PDF PubMed Scopus (164) Google Scholar there was a critical need for nephrologists and PCPs to work together to implement evidence-based clinical practice guidelines for patients with CKD. In another national study, it was demonstrated that this lack of awareness of the guidelines extended down to the level of internal medicine resident trainees.3Agrawal V. Ghosh A.K. Barnes M.A. McCullough P.A. Awareness and Knowledge of Clinical Practice Guidelines for CKD Among Internal Medicine Residents: A National Online Survey.in: Elsevier Inc, 2008: 1061-1069Google Scholar The lack of awareness or appreciation of CKD as a public health issue is surprising considering that the prevalence of CKD is 13% in the adult US population.4Coresh J. Astor B.C. Greene T. Eknoyan G. Levey A.S. Prevalence of chronic kidney disease and decreased kidney function in the adult US population: Third National Health and Nutrition Examination Survey.Am J Kidney Dis. 2003; 41: 1-12Abstract Full Text Full Text PDF PubMed Scopus (2293) Google Scholar Additionally, on a per-person basis, CKD is the most expensive of all the chronic diseases that Medicare funds. The US Renal Data System annual report of 2011 observes that although “patients with CKD represent only 7.6 percent of the population, their care accounts for 22.3 percent of total expenditures.”5US Renal Data SystemUSRDS 2011 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States.Am J Kidney Dis. 2012; 59(1): e1-e420Google Scholar CKD is a chronic disease that is well suited for the PCP to manage in its early stages. PCPs are accustomed to helping patients manage complex chronic conditions as part of routine primary care.6Fortin M. Bravo G. Hudon C. Vanasse A. Lapointe L. Prevalence of multimorbidity among adults seen in family practice.Ann Fam Med. 2005; 3: 223-228Crossref PubMed Scopus (690) Google Scholar Several simple interventions, such as initiating treatment with an angiotensin-converting enzyme inhibitor7Jafar T.H. Schmid C.H. Landa M. et al.Angiotensin-converting enzyme inhibitors and progression of nondiabetic renal disease A meta-analysis of patient-level data.Ann Intern Med. 2001; 135: 73-87Crossref PubMed Scopus (886) Google Scholar and avoiding a nonsteroidal anti-inflammatory drug,8Gooch K. Culleton B.F. Manns B.J. et al.NSAID Use and Progression of Chronic Kidney Disease.in: Elsevier, 2007: 280Google Scholar will save lives, reduce costs, and improve quality of life. This is the essence of primary care. Although PCPs are trained and accomplished in managing complex comorbid conditions, it is well known that patients receive only about one-half of the solid evidence-based care they need.9McGlynn E.A. Asch S.M. Adams J. et al.The Quality of Health Care Delivered to Adults in the United States.in: Mass Med Soc, 2003: 2635Google Scholar The competing demands10Jaen C.R. Stange K.C. Nutting P.A. Competing demands of primary care: a model for the delivery of clinical preventive services.J Fam Pract. 1994; 38: 166-171PubMed Google Scholar of having to deal with multiple problems simultaneously results in a lack of sufficient time to do the required work. This was clearly highlighted by 2 studies from the Duke University School of Public Health that demonstrated that it takes 7.4 hours per patient per year to complete screening and preventive services11Yarnall K.S. Pollak K.I. Ostbye T. Krause K.M. Michener J.L. Primary care: is there enough time for prevention?.Am J Public Health. 2003; 93: 635-641Crossref PubMed Scopus (1267) Google Scholar and a minimum of at least 3.5 hours to manage each patient's chronic diseases.12Ostbye T. Yarnall K.S. Krause K.M. et al.Is there time for management of patients with chronic diseases in primary care?.Ann Fam Med. 2005; 3: 209-214Crossref PubMed Scopus (567) Google Scholar Early qualitative work demonstrated that PCPs were unaware of practice guidelines, but they were eager to have guidance on how to manage CKD, just as they had guidance for diabetes and hypertension. This study also demonstrated the need for better communication between PCPs and nephrologists. There is a need for clearer guidelines for when to refer and how to comanage patients with CKD.13Fox C.H. Brooks A. Zayas L.E. McClellan W. Murray B. Primary care physicians' knowledge and practice patterns in the treatment of chronic kidney disease: an Upstate New York Practice-based Research Network (UNYNET) study.J Am Board Fam Med. 2006; 19: 54-61Crossref PubMed Scopus (96) Google Scholar From these humble beginnings, much has been accomplished in the 10 years since the KDOQI CKD guidelines were published. Progress has occurred in 3 major areas: (1) the almost universal reporting of estimated glomerular filtration rate (eGFR), as the best screening test routinely available to assess kidney function, on clinical laboratory reports when serum creatinine is measured; (2) the increasing PCP interest and awareness of the importance of CKD; and (3) the emergence of primary care translational research that transforms evidence into routine daily primary care practice. The good news is that it has been shown that the routine reporting of eGFR has led to improvement in intermediate clinical outcomes, such as physician awareness and earlier referral to nephrologists.14Richards N. Harris K. Whitfield M. et al.Primary care-based disease management of chronic kidney disease (CKD), based on estimated glomerular filtration rate (eGFR) reporting, improves patient outcomes.Nephrol Dial Transplant. 2008; 23: 549-555Crossref PubMed Scopus (83) Google Scholar, 15Fox C.H. Swanson A. Kahn L.S. Glaser K. Murray B.M. Improving chronic kidney disease care in primary care practices: an Upstate New York Practice-based Research Network (UNYNET) Study.J Am Board Fam Med. 2008; 21: 522-530Crossref PubMed Scopus (47) Google Scholar, 16Kagoma Y.K. Weir M.A. Iansavichus A.V. et al.Impact of estimated GFR reporting on patients, clinicians, and health-care systems: a systematic review.Am J Kidney Dis. 2011; 57: 592-601Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar Despite this, studies are mixed about whether reporting of eGFR results in improved patient outcomes, such as reduction in cardiovascular risk factors and the rate of decreased kidney function, mortality, or the need for renal replacement therapy.17Manns B. Tonelli M. Culleton B. et al.A cluster randomized trial of an enhanced eGFR prompt in chronic kidney disease.Clin J Am Soc Nephrol. 2012; 7: 565-572Crossref PubMed Scopus (37) Google Scholar Led by the Niagara Health Quality Coalition, the Western New York CKD task force was able to convince a major national laboratory to automatically report eGFR every time serum creatinine was ordered. This later became routine in most laboratories. Automatic eGFR reporting increased appropriate referrals to nephrologists, but it also highlighted the need for intensified educational activities for PCPs in the detection and treatment of CKD.18Hemmelgarn B.R. Zhang J. Manns B.J. et al.Nephrology visits and health care resource use before and after reporting estimated glomerular filtration rate.JAMA. 2010; 303: 1151-1158Crossref PubMed Scopus (135) Google Scholar, 19Noble E. Johnson D.W. Gray N. et al.The impact of automated eGFR reporting and education on nephrology service referrals.Nephrol Dial Transplant. 2008; 23: 3845-3850Crossref PubMed Scopus (68) Google Scholar Although the KDOQI guidelines recommend that patients with eGFR <30 mL/min/1.73 m2, or CKD stage 4, have a nephrology consult, most patients with CKD stage 3 are seen exclusively in primary care offices, making it imperative that we have better educational tools.20McClellan W. Aronoff S.L. Bolton W.K. et al.The prevalence of anemia in patients with chronic kidney disease.Curr Med Res Opin. 2004; 20: 1501-1510Crossref PubMed Scopus (342) Google Scholar Also, although eGFR is routinely reported, preliminary unpublished data from a study funded by the NKF regarding the implementation of KDOQI guidelines in primary care practices demonstrated that once patients met criteria for CKD stage 3 by eGFR results, the diagnosis of CKD was present in the chart on average only 25% of the time. Currently, there is increasing awareness on the part of the primary care community of the importance of CKD. Each year, there are more requests to have this topic as part of continuing medical education, and the NKF is collaborating with the American Academy of Family Physicians and the American College of Physicians to have a joint session at the NKF Spring Clinical Meetings. This collaboration will use a case-based approach to train PCPs in the management of CKD. It is to be hoped that this will be an annual occurrence. Two authors of this editorial, a family physician (C.H.F.) and a nephrologist (J.V.), have combined to develop a quick reference guide for PCPs about treating CKD, which has been distilled into a 1-page guideline summary. Dissemination and simplification is growing, which is an encouraging sign.21Fox C.H. Voleti V. Khan L.S. Murray B. Vassalotti J. A quick guide to evidence-based chronic kidney disease care for the primary care physician.Postgrad Med. 2008; 120: E01-E06Crossref Scopus (15) Google Scholar Interest among PCPs to incorporate evidence-based management of patients with CKD has spawned translational research to disseminate and implement the KDOQI guidelines in primary care practices. The University of Oklahoma has a large Agency for Health Research and Quality grant to implement the guidelines in 92 primary care practices using practice facilitation and collaborative learning groups. The University at Buffalo has a comparative effectiveness grant in 40 PCP practices nationally using the Distributed Area Research and Therapeutics Network (DARTNet).22Pace W.D. Cifuentes M. Valuck R.J. et al.An electronic practice-based network for observational comparative effectiveness research [see comment].Ann Intern Med. 2009; 151: 338-340Crossref PubMed Scopus (62) Google Scholar In addition, the National Institute of Diabetes, Digestive and Kidney Diseases (NIDDK) has begun funding translational grants to improve the early detection and treatment of CKD. The first 2 pilot studies in this research portfolio were funded in fall 2011 (NIDDK project numbers 1R34DK094116 and 1R34DK093992). From a primary care perspective, the 2002 KDOQI CKD guidelines have been invaluable for better detection and treatment of CKD, but a lot remains to be accomplished in order to disseminate and implement these guidelines. Studies are needed to assess patient perspectives and preferences across the spectrum of CKD to inform interventions that will improve patient self-management.23Tong A. Sainsbury P. Chadban S. et al.Patients' experiences and perspectives of living with CKD.Am J Kidney Dis. 2009; 53: 689-700Abstract Full Text Full Text PDF PubMed Scopus (137) Google Scholar Involving the patient through engagement, education, and empowerment in self-management will be critical to reducing the public health burden of CKD. Ongoing collaboration between PCPs and nephrologists is integral to future implementation of CKD clinical practice guidelines. Financial Disclosure: Dr Vassalotti is the NKF Chief Medical Officer and is on the Litholink Corp CKD Advisory Board. Dr Vassalotti has consulted for CTI Clinical Trial Services and has been a speaker for Gore Creative Technologies, Inc, and Elsevier, Inc. The other authors declare that they have no relevant financial interests.