Management
Several recent studies have investigated the management of CKD in primary care and highlighted widespread deficiencies. In England, a study of 1741 people with CKD stage 3 from 32 primary care practices found that only 60% of those with hypertension achieved the KDIGO targets for blood pressure and 8% were prescribed potentially nephrotoxic drugs. In the USA, a study of 11 774 people with CKD stages 3–4 found blood pressure control to the KDOQI target of less than 130/80 in only 54%, lack of annual urine testing in 70% and use of potentially harmful drugs in 26%. In Australia, one study of 1312 people with abnormal kidney function in primary care reported that antihypertensives were indicated in 51% and lipid-lowering agents in 46% of people not receiving these medications, whereas blood pressure targets were achieved in only 61% and lipid targets in only 50% of those receiving drug therapy. Similarly, in Switzerland, the KDOQI target for blood pressure was achieved in only 30% of people with CKD. Though these data paint a bleak picture of CKD management in primary care, it must be conceded that this is not limited to primary care. In a large study cohort of 3612 people with CKD based in secondary care in the USA, blood pressure was controlled to less than 140/90 mmHg in only 67% and less than 130/80 mmHg in 46%. Hypertension control rates were similar for people who had or had not previously been seen by a nephrologist. Similarly, in a cohort of 1691 people referred to a Nephrology Department in the UK, only 42% had blood pressure controlled to less than 140/80 mmHg.
Several studies have sought to investigate the factors contributing to deficiencies in CKD management in primary care. One qualitative study using focus groups of primary care physicians and nurses identified doubts about a diagnosis of CKD based on eGFR alone and whether CKD in older people was part of normal ageing rather than a separate disease process as possible contributing factors. Concern was also expressed about the challenge of explaining a diagnosis of CKD without frightening patients. There was scepticism regarding blood pressure targets, but the need for more education on CKD was acknowledged. Similarly, semi-structured interviews with 11 primary care doctors and 10 nurses revealed concerns regarding the relevance of a mild reduction in eGFR in the elderly and the risk of provoking anxiety by discussing the diagnosis with patients. In another study, a questionnaire was used to assess practitioner confidence in managing different aspects of CKD amongst 148 primary care doctors and nurses. Confidence in treating hypertension alone (87% confident) was higher than confidence treating hypertension in the setting of CKD (59% confident) or CKD and diabetes (61% confident). In addition, 43% lacked confidence in identifying significant proteinuria and only 42% were confident in using proteinuria results to manage CKD. Male doctors were more confident than female doctors; doctors were more confident than nurses; doctors younger than 35 years were more confident than those aged 35–54 years, but doctors over 54 years were also more confident than the middle group. Taken together, these studies suggest that uncertainty and concerns about the risks versus benefits of diagnosing early stage CKD as well as lack of knowledge and confidence regarding the management of CKD contribute to the management deficiencies in primary care. These findings highlight the need to improve education and training on the management of CKD amongst primary care practitioners.
A number of interventions to improve CKD management in primary care have been evaluated ( Table 2 ) . The introduction of automated reporting of eGFR with serum creatinine results increased recognition of CKD and referral to a nephrologist, but the addition of an enhanced prompt with specific management recommendations did not produce additional improvement. In a large cluster randomized trial, introduction of an enhanced prompt was associated with no increase in appropriate prescription of renin–angiotensin–aldosterone system inhibitors (RAASi) except in elderly people with CKD stage 4 and there was no improvement in outcomes (doubling of serum creatinine or ESKD or hospitalization with CVE). There was a small improvement in testing for proteinuria, but no effect on testing for dyslipidaemia, haemoglobin A1C, glycaemic control or referral to a nephrologist. These findings should, however, be interpreted in light of the fact that prescription of RAASi was highly prevalent (~77%) prior to the intervention and there may, therefore, have been limited scope for further improvement. In England, a pay for performance programme, the Quality and Outcomes Framework (QOF) was introduced to improve performance in primary care across a broad range of conditions and CKD-specific indicators were added in 2006. A large cohort study of 10 040 people with CKD stages 3–5 reported a significant improvement in mean achieved blood pressure amongst hypertensive patients from 146/79 mmHg before QOF to 140/76 mmHg in the first 2 years of QOF and 139/75 mmHg in 2008–2010. Overall, the proportion of people with CKD achieving a blood pressure target of less than 140/85 mmHg increased from 41.5 to 50.0%, and amongst those with hypertension at baseline, the proportion increased from 28.8 to 45.1%. A recent cluster randomized study compared the impact of audit-based education (ABE, an intervention comprising audit of practice performance, meetings to feed back data and education) with provision of guidelines and no intervention in 93 primary care practices. After 2 years, ABE was associated with a mean reduction in systolic blood pressure of 2.41 mmHg [confidence interval (CI) 0.59–4.29 mmHg] and a significantly increased odds ratio of achieving at least a 5-mmHg reduction in systolic blood pressure (odds ratio 1.24; CI 1.05–1.45) versus no intervention. Provision of guidelines was not associated with any significant improvement. There is a growing interest in the use of telemedicine and self-management to improve the management of all long-term conditions. One recent study evaluated the use of a simple telemedicine intervention to improve blood pressure control in 126 people with hypertension, of whom 23 also had CKD stages 3–5. Participants were reminded to check their own blood pressure by text message sent to their mobile phones and submitted blood pressure readings by text message. The primary healthcare team reviewed the results, and advice regarding further management was sent back via text message. In a case–control analysis, blood pressure was higher in the intervention group than controls at baseline. After 3 months, the intervention was associated with a greater reduction in systolic blood pressure, more frequent blood pressure readings and more changes in antihypertensive medication such that blood pressure was similar in the intervention and control groups. In a randomized trial, an Internet-based, nurse led management programme in people with cardiovascular disease was found to reduce Framingham risk score by 14% versus controls, but this approach has not yet been formally evaluated in people with CKD.