Nephrology co-management versus primary care solo management for early chronic kidney disease: a retrospective cross-sectional analysis

摘要

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?p?=?p?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). Conclusion 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.