Quality of Care in Chronic Kidney Disease and Incidence of End-stage Renal Disease in Older Patients: A Cohort Study.

Abstract

The quality of care received by a growing number of older patients with chronic kidney disease (CKD) has not been adequately examined. The objective of this study was to assess the quality of CKD care among older patients and to clarify its association with the incidence of end-stage renal disease (ESRD). This was a population-based cohort study. Older (65 y and above) CKD patients diagnosed between October 2010 and September 2014 from the National Database of Health Insurance Claims of Japan. A composite quality score (QS) of 3 quality measures for CKD care during the 6 months after CKD diagnosis was computed. The validated quality measures included urine testing for proteinuria, nutritional guidance, and nonsteroidal anti-inflammatory drugs avoidance. To assess the association between the QS and ESRD incidence, we used instrumental variable analysis after stratification for the history of diabetes. Among the 890,773 older CKD patients, 2.9% progressed to ESRD (incidence rate of 12.5 per thousand person-years). In total, 59.9% underwent urine testing, 4.5% received nutritional guidance, and 91.2% avoided regular use of nonsteroidal anti-inflammatory drugs. An instrumental variable analysis revealed that a higher QS was associated with-lower ESRD incidence in patients diagnosed with diabetes (hazard ratio: 0.25, 95% confidence interval: 0.24-0.27 for each point higher score) but not in patients without a diagnosis of diabetes (hazard ratio: 0.99, 95% confidence interval: 0.92-1.05). Among older CKD patients, quality of CKD care varied between patients, and better quality of CKD care was associated with a lower ESRD incidence in patients with diabetes but not in nondiabetic patients.