Chronic Kidney Disease Patients Face Continual, Significant Gaps in Care

Patients with chronic kidney disease (CKD) have a high prevalence of uncontrolled hypertension and diabetes, as well as statin use below the recommended guidelines for cholesterol control, according to a study by researchers at UC San Francisco.

While effective treatments exist for the more than 30 million Americans with CKD, nearly 50 percent of such patients analyzed from 2006 to 2014 continued to suffer from uncontrolled hypertension and 40 percent from uncontrolled diabetes, the researchers said. The study appears online July 11, 2019, in the Clinical Journal of the American Society of Nephrology. 

“Even when physicians are aware of a patient’s CKD diagnosis, there are substantial gaps in quality of care,” said lead author Sri Lekha Tummalapalli, MD, MBA, a nephrology fellow at UCSF. “The lack of improvement over a decade highlights a more urgent need for CKD-specific quality measures and the implementation of quality-improvement interventions.”

CKD, a condition of reduced kidney function or kidney damage, affects about 13.6 percent of the U.S. adult population and is expected to grow to 14.4 percent by 2020 and 16.7 percent by 2030. Combined with end-stage renal disease (ESRD), it results in high morbidity, mortality and health care costs. According to the U.S. Renal Data System, among fee-for-service Medicare patients, total medical costs in 2016 exceeded $79 billion for CKD and another $35 billion for ESRD patients. 

However, CKD management is complex, involving multiple interventions to protect patient health and prevent kidney failure, such as lifestyle changes and/or medications that control hypertension, high cholesterol and diabetes. 

In the study, Tummalapalli and her colleagues used the National Ambulatory Medical Care Survey to review visits by CKD patients to office-based outpatient practices over a 9-year period. They reviewed blood pressure measurement, uncontrolled hypertension and uncontrolled diabetes, as well as the use of certain medications in patients with hypertension, statins if aged 50 years and older, and nonsteroidal anti-inflammatory drugs (NSAIDs). 

Overall, they assessed 7,099 visits for CKD patients. No statistically significant difference was found in the prevalence of uncontrolled hypertension over time: 46 percent in 2006-2008 to 48 percent in 2012-2014. They also found that 40 percent of the patients had uncontrolled diabetes in 2012-2014. NSAID use recorded in the medical record was low, averaging 3 percent from 2006 to 2014. Statin use in CKD patients aged 50 years and older with high cholesterol was low and statistically unchanged during the study period, from 29 percent in 2006-2008 to 31 percent in 2012-2014, despite guidelines for their use by the American College of Cardiology and the American Heart Association.

The researchers cited a lack of dedicated, specific quality metrics and insufficient knowledge of specific guidelines for the overall poor quality of CKD care. Low rates of nephrology referral may further drive decreased adherence to quality indicators, they said, along with payment models and care delivery systems that do not support population health-based interventions. 

Most CKD is treated in primary care settings, so efforts towards improved CKD management must involve primary care physicians as a central component of multispecialty care teams, Tummalapalli said, while addressing their limited time and competing demands.

“Chronic disease management in all patients, and particularly those with CKD, is essential to slow disease progression and reduce the risk of kidney failure and cardiovascular events,” Tummalapalli said. “Improving the control of hypertension and diabetes is extremely challenging and requires multifaceted efforts to deliver care more effectively and support lifestyle modification and medication adherence. Building these systems that are efficient and scalable will be the task of health care over the next decade.”

Co-Authors: Senior authors Salomeh Keyhani and Neil R. Powe, of UCSF.

Funding: Funding was provided by the National Institute of Diabetes and Digestive and Kidney Diseases (2T32DK007219-41, UCSF training grant).

Disclosures: The authors report no conflicts of interest.

The University of California, San Francisco (UCSF) is exclusively focused on the health sciences and is dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It includes UCSF Health, which comprises three top-ranked hospitals, as well as affiliations throughout the Bay Area.