title: Nephrology co-management versus primary care solo management for early chronic kidney disease: a retrospective cross-sectional analysis.
abstract: BACKGROUND
  Primary care physicians (PCPs) typically manage early chronic kidney disease (CKD), but recent guidelines recommend nephrology co-management for some patients with stage 3 CKD and all patients with stage 4 CKD. We sought to compare quality of care for co-managed patients to solo managed patients.
  
  
  METHODS
  We conducted a retrospective cross-sectional analysis. Patients included in the study were adults who visited a PCP during 2009 with laboratory evidence of CKD in the preceding two years, defined as two estimated glomerular filtration rates (eGFR) between 15-59 mL/min/1.73 m(2) separated by 90 days. We assessed process measures (serum eGFR test, urine protein/albumin test, angiotensin converting enzyme inhibitor or angiotensin receptor blocker [ACE/ARB] prescription, and several tests monitoring for complications) and intermediate clinical outcomes (mean blood pressure and blood pressure control) and performed subgroup analyses by CKD stage.
  
  
  RESULTS
  Of 3118 patients, 11 % were co-managed by a nephrologist. Co-management was associated with younger age (69 vs. 74 years), male gender (46 % vs. 34 %), minority race/ethnicity (black 32 % vs. 22 %; Hispanic 13 % vs. 8 %), hypertension (75 % vs. 66 %), diabetes (42 % vs. 26 %), and more PCP visits (5.0 vs. 3.9; p < 0.001 for all comparisons). After adjustment, co-management was associated with serum eGFR test (98 % vs. 94 %, p = <0.0001), urine protein/albumin test (82 % vs 36 %, p < 0.0001), and ACE/ARB prescription (77 % vs. 69 %, p = 0.03). Co-management was associated with monitoring for anemia and metabolic bone disease, but was not associated with lipid monitoring, differences in mean blood pressure (133/69 mmHg vs. 131/70 mmHg, p > 0.50) or blood pressure control. A subgroup analysis of Stage 4 CKD patients did not show a significant association between co-management and ACE/ARB prescription (80 % vs. 73 %, p = 0.26).
  
  
  CONCLUSIONS
  For stage 3 and 4 CKD patients, nephrology co-management was associated with increased stage-appropriate monitoring and ACE/ARB prescribing, but not improved blood pressure control.
authors.affiliation: Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont St., Boston, MA, 02120-1613, USA. lsamal@partners.org.|Harvard Medical School, Boston, MA, 02120, USA. lsamal@partners.org.
authors.forename: Lipika
authors.initials: L
authors.lastname: Samal
authors.affiliation: Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont St., Boston, MA, 02120-1613, USA. awright@partners.org.|Harvard Medical School, Boston, MA, 02120, USA. awright@partners.org.
authors.forename: Adam
authors.initials: A
authors.lastname: Wright
authors.affiliation: Harvard Medical School, Boston, MA, 02120, USA. swaikar@partners.org.|Renal Division, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02120, USA. swaikar@partners.org.
authors.forename: Sushrut S
authors.initials: SS
authors.lastname: Waikar
authors.affiliation: Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont St., Boston, MA, 02120-1613, USA. jlinder@partners.org.|Harvard Medical School, Boston, MA, 02120, USA. jlinder@partners.org.
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Linder
mesh_terms: D001741:Black or African American / Q000706:statistics & numerical data*; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D015897:Comorbidity; D003430:Cross-Sectional Studies; D003920:Diabetes Mellitus / Q000453:epidemiology; D011307:Drug Prescriptions / Q000706:statistics & numerical data; D005260:Female; D005919:Glomerular Filtration Rate; D006630:Hispanic or Latino / Q000706:statistics & numerical data*; D006801:Humans; D006973:Hypertension / Q000453:epidemiology; D007677:Kidney Function Tests / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D008913:Minority Groups / Q000706:statistics & numerical data*; D009398:Nephrology / Q000592:standards* / Q000706:statistics & numerical data; D009819:Office Visits / Q000706:statistics & numerical data; D010043:Outcome and Process Assessment, Health Care; D010348:Patient Care Team / Q000458:organization & administration*; D011320:Primary Health Care / Q000592:standards* / Q000706:statistics & numerical data; D019984:Quality Indicators, Health Care; D051436:Renal Insufficiency, Chronic / Q000453:epidemiology / Q000503:physiopathology / Q000628:therapy*; D012189:Retrospective Studies; D012737:Sex Factors; D014481:United States / Q000453:epidemiology; D016482:Urinalysis / Q000706:statistics & numerical data
chemical_list: D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors