title: Adherence to chronic kidney disease guidelines in primary care patients is associated with comorbidity.
abstract: GPs insufficiently follow guidelines regarding consultation and referral for chronic kidney disease (CKD).
  
  
  
  To identify patient characteristics and quality of care (QoC) in CKD patients with whom consultation and referral recommendations were not followed.
  
  
  
  A 14 month prospective observational cohort study of primary care patients with CKD stage 3-5. 47 practices participated, serving 207469 people. 2547 CKD patients fulfilled consultation criteria, 225 fulfilled referral criteria. We compared characteristics of patients managed by GPs with patients receiving nephrologist co-management. We assessed QoC as adherence to monitoring criteria, CKD recognition and achievement of blood pressure (BP) targets.
  
  
  
  Patients treated in primary care despite a consultation recommendation (94%) had higher eGFR values (OR 1.07; 95% CI: 1.05-1.09), were less often monitored for renal function (OR 0.42; 95% CI: 0.24-0.74) and potassium (OR 0.56; 95% CI: 0.35-0.92) and CKD was less frequently recognised (OR 0.46; 95% CI: 0.31-0.68) than in patients with nephrologist co-management. Patients treated in primary care despite referral recommendation (70%) were older (OR 1.03; 95% CI:1.01-1.06) and had less cardiovascular disease (OR 0.37; 95% CI: 0.19-0.73). Overall, in patients solely managed by GPs, CKD recognition was 50%, monitoring disease progression in 36% and metabolic parameters in 3%, BP targets were achieved in 51%. Monitoring of renal function and BP was positively associated with diabetes (OR 3.10; 95% CI: 2.47-3.88 and OR 7.78; 95% CI: 3.21-18.87) and hypertension (OR 3.19; 95% CI: 2.67-3.82 and OR 3.35; 95% CI: 1.45-7.77).
  
  
  
  Patients remaining in primary care despite nephrologists' co-management recommendations were inadequately monitored, and BP targets were insufficiently met. CKD patients without cardiovascular comorbidity or diabetes require extra attention to guarantee adequate monitoring of renal function and BP.
authors.affiliation: Department of Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands.
authors.forename: Carola
authors.initials: C
authors.lastname: van Dipten
authors.affiliation: Department of Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands.
authors.forename: Saskia
authors.initials: S
authors.lastname: van Berkel
authors.affiliation: Department of Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands.
authors.forename: Vincent A
authors.initials: VA
authors.lastname: van Gelder
authors.affiliation: Department of Nephrology, Radboud university medical center, Nijmegen, The Netherlands.
authors.forename: Jack F M
authors.initials: JFM
authors.lastname: Wetzels
authors.affiliation: Department of Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands.
authors.forename: Reinier P
authors.initials: RP
authors.lastname: Akkermans
authors.affiliation: Department of Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands.
authors.forename: Wim J C
authors.initials: WJC
authors.lastname: de Grauw
authors.affiliation: Department of Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands.
authors.forename: Marion C J
authors.initials: MCJ
authors.lastname: Biermans
authors.affiliation: Department of Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands.
authors.forename: Nynke D
authors.initials: ND
authors.lastname: Scherpbier-de Haan
authors.affiliation: Department of Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands.
authors.forename: Willem J J
authors.initials: WJJ
authors.lastname: Assendelft
mesh_terms: D000368:Aged; D015897:Comorbidity; D019468:Disease Management; D005260:Female; D005919:Glomerular Filtration Rate / Q000502:physiology; D017408:Guidelines as Topic; D006801:Humans; D006973:Hypertension / Q000628:therapy; D008297:Male; D011320:Primary Health Care / Q000592:standards*; D011446:Prospective Studies; D011787:Quality of Health Care / Q000592:standards; D012017:Referral and Consultation / Q000592:standards*; D051436:Renal Insufficiency, Chronic / Q000628:therapy*; D012307:Risk Factors
keywords: Chronic kidney disease; electronic medical records; nephrology; patient care management; primary health care; referral and consultation