title: Delivery patterns of recommended chronic kidney disease care in clinical practice: administrative claims-based analysis and systematic literature review.
abstract: BACKGROUND
  Clinical practice guidelines for management of chronic kidney disease (CKD) have been developed within the Kidney Disease Outcomes Quality Initiative (K/DOQI). Adherence patterns may identify focus areas for quality improvement.
  
  
  METHODS
  We retrospectively studied contemporary CKD care patterns within a private health system in the United States, and systematically reviewed literature of reported practices internationally. Five hundred and nineteen patients with moderate CKD (estimated GFR 30-59 ml/min) using healthcare benefits in 2002-2005 were identified from administrative insurance records. Thirty-three relevant publications in 2000-2006 describing care in 77,588 CKD patients were reviewed. Baseline demographic traits and provider specialty were considered as correlates of delivered care. Testing consistent with K/DOQI guidelines and prevalence of angiotensin converting enzyme inhibitor/angiotensin receptor blocker (ACEi/ARB) medication prescriptions were ascertained from billing claims. Care descriptions in the literature sample were based on medical charts, electronic records and/or claims.
  
  
  RESULTS
  KDOQI-consistent measurements of parathyroid hormone (7.1 vs. 0.6%, P = 0.0002), phosphorus (38.2 vs. 1.9%, P < 0.0001) and quantified urinary protein (23.8 vs. 9.4%, P = 0.008) were more common among CKD patients with versus without nephrology referral in the administrative data. Nephrology referral correlated with increased likelihood of testing for parathyroid hormone and phosphorus after adjustment for baseline patient factors. Use of ACEi/ARB medications was more common among patients with nephrology contact (50.0 vs. 30.0%; P = 0.008) but appeared largely driven by higher comorbidity burden. The literature review demonstrated similar practice patterns.
  
  
  CONCLUSIONS
  Delivery of CKD care may be monitored by administrative data. There is opportunity for improvement in CKD guideline adherence in practice.
authors.affiliation: Division of Nephrology, Saint Louis University School of Medicine, St Louis, MO 63104, USA.
authors.forename: Marie D
authors.initials: MD
authors.lastname: Philipneri
authors.forename: Lisa A
authors.initials: LA
authors.lastname: Rocca Rey
authors.forename: Mark A
authors.initials: MA
authors.lastname: Schnitzler
authors.forename: Kevin C
authors.initials: KC
authors.lastname: Abbott
authors.forename: Daniel C
authors.initials: DC
authors.lastname: Brennan
authors.forename: Steven K
authors.initials: SK
authors.lastname: Takemoto
authors.forename: Paula M
authors.initials: PM
authors.lastname: Buchanan
authors.forename: Thomas E
authors.initials: TE
authors.lastname: Burroughs
authors.forename: Lisa M
authors.initials: LM
authors.lastname: Willoughby
authors.forename: Krista L
authors.initials: KL
authors.lastname: Lentine
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D047228:Angiotensin II Type 1 Receptor Blockers / Q000627:therapeutic use; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D015897:Comorbidity; D003404:Creatinine / Q000097:blood; D048909:Diabetes Complications / Q000628:therapy; D050171:Dyslipidemias / Q000175:diagnosis; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D006973:Hypertension / Q000150:complications; D007345:Insurance Claim Review; D007676:Kidney Failure, Chronic / Q000150:complications / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D009398:Nephrology / Q000592:standards*; D010281:Parathyroid Hormone / Q000097:blood; D017410:Practice Guidelines as Topic; D012017:Referral and Consultation; D012189:Retrospective Studies
chemical_list: D047228:Angiotensin II Type 1 Receptor Blockers; D000806:Angiotensin-Converting Enzyme Inhibitors; D010281:Parathyroid Hormone; D003404:Creatinine