Given the high prevalence of chronic kidney disease (CKD), primary care physicians (PCPs) frequently manage early stage CKD. Nonetheless, there are challenges in providing optimal CKD care in the ...primary care setting. This study sought to understand PCPs' perceptions of barriers and facilitators to the optimal management of CKD.
Mixed methods study.
Community-based PCPs in four US cities: Baltimore, MD; St. Louis, MO; Raleigh, NC and San Francisco, CA.
We used a self-administered questionnaire and conducted 4 focus groups of PCPs (n = 8 PCPs/focus group) in each city to identify key barriers and facilitators to management of patients with CKD in primary care.
We conducted descriptive analyses of the survey data. Major themes were identified from audio-recorded interviews that were transcribed and coded by the research team.
Of 32 participating PCPs, 31 (97%) had been in practice for >10 years, and 29 (91%) practiced in a non-academic setting. PCPs identified multiple barriers to managing CKD in primary care including at the level of the patient (e.g., low awareness of CKD, poor adherence to treatment recommendations), the provider (e.g., staying current with CKD guidelines), and the health care system (e.g., inflexible electronic medical record, limited time and resources). PCPs desired electronic prompts and lab decision support, concise guidelines, and healthcare financing reform to improve CKD care.
PCPs face substantial but modifiable barriers in providing care to patients with CKD. Interventions that address these barriers and promote facilitative tools may improve PCPs' effectiveness and capacity to care for patients with CKD.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Several reports show that patients with chronic disease who are empowered with information technology (IT) tools for monitoring, training and self-management have improved outcomes, however there are ...few such applications employed in kidney disease. This review explores the current and potential uses of health IT platforms to advance kidney disease care by offering innovative solutions to inform, engage and communicate with individuals with CKD.
Kidney disease continues to manifest stark racial inequities in the United States, revealing the entrenchment of racism and bias within multiple facets of society, including in our institutions, ...practices, norms, and beliefs. In this perspective, we synthesize theory and evidence to describe why an understanding of race and racism is integral to kidney care, providing examples of how kidney health disparities manifest interpersonal and structural racism. We then describe racialized medicine and “colorblind” approaches as well as their pitfalls, offering in their place suggestions to embed antiracism and an “equity lens” into our practice. We propose examples of how we can enhance kidney health equity by enhancing our structural competency, using equity-focused race consciousness, and centering investigation and solutions around the needs of the most marginalized. To achieve equitable outcomes for all, our medical institutions must embed antiracism and equity into all aspects of advocacy, policy, patient/community engagement, educational efforts, and clinical care processes. Organizations engaged in kidney care should commit to promoting structural equity and eliminating potential sources of bias across referral practices, guidelines, research agendas, and clinical care. Kidney care providers should reaffirm our commitment to structurally competent patient care and educational endeavors in which empathy and continuous self-education about social drivers of health and inequity, racism, and bias are integral. We envision a future in which kidney health equity is a reality for all. Through bold collective and sustained investment, we can achieve this critical goal.
Recent changes to the U.S. Food and Drug Administration boxed warning for metformin will increase its use in persons with historical contraindications or precautions. Prescribers must understand the ...clinical outcomes of metformin use in these populations.
To synthesize data addressing outcomes of metformin use in populations with type 2 diabetes and moderate to severe chronic kidney disease (CKD), congestive heart failure (CHF), or chronic liver disease (CLD) with hepatic impairment.
MEDLINE (via PubMed) from January 1994 to September 2016, and Cochrane Library, EMBASE, and International Pharmaceutical Abstracts from January 1994 to November 2015.
English-language studies that: 1) examined adults with type 2 diabetes and CKD (with estimated glomerular filtration rate less than 60 mL/min/1.73 m2), CHF, or CLD with hepatic impairment; 2) compared diabetes regimens that included metformin with those that did not; and 3) reported all-cause mortality, major adverse cardiovascular events, and other outcomes of interest.
2 reviewers abstracted data and independently rated study quality and strength of evidence.
On the basis of quantitative and qualitative syntheses involving 17 observational studies, metformin use is associated with reduced all-cause mortality in patients with CKD, CHF, or CLD with hepatic impairment, and with fewer heart failure readmissions in patients with CKD or CHF.
Strength of evidence was low, and data on multiple outcomes of interest were sparse. Available studies were observational and varied in follow-up duration.
Metformin use in patients with moderate CKD, CHF, or CLD with hepatic impairment is associated with improvements in key clinical outcomes. Our findings support the recent changes in metformin labeling.
U.S. Department of Veterans Affairs. (PROSPERO: CRD42016027708).
Many aspects of CKD management rely heavily on patient self-care, including medication and dietary adherence, self-monitoring of BP, and daily physical activity. Growing evidence suggests that ...incorporating smartphone-based applications can support self-care in CKD and chronic disease more generally.
We identified applications targeting patients with CKD by conducting a search of the US Apple App Store (iOS) and Google Play Store (Android) using the following four phrases: "kidney disease," "renal," "dialysis," and "kidney transplant." We considered the first 50 applications for each search term on each application store. We adapted a previously described framework for assessment of mobile health applications to account for kidney disease-specific content areas and evaluated applications on their types of patient engagement, quality, usability, and safety. Engagement and quality were assessed by both a patient and a nephrologist, usability was assessed by a patient, and safety was assessed by a nephrologist. Overall, two patients with CKD and three nephrologists performed the evaluations. We examined pairwise correlations between patient, nephrologist, and consumer ratings of application quality.
Our search strategy identified 174 unique applications on Android and 165 unique applications on iOS. After excluding applications that were not related to kidney disease, were not patient facing, or were last updated before 2014, 12 Android-only applications, 11 iOS-only applications, and five dual-platform applications remained. Patient and nephrologist application quality ratings, assessed by the net promoter score, were not correlated (
=0.36;
=0.06). Consumer ratings on the application stores did not correlate with patient ratings of application quality (
=0.34;
=0.18).
Only a small subset of CKD applications was highly rated by both patients and nephrologists. Patients' impressions of application quality are not directly linked to consumer application ratings or nephrologist impressions.
Community-acquired acute kidney injury (CA-AKI) develops outside of the hospital and is the most common form of AKI globally. National estimates of CA-AKI in the United States are absent due to ...limited availability of laboratory data. This study leverages national data from the Veterans Health Administration (VA) to estimate incidence and risk factors of CA-AKI.
Retrospective cohort study using national VA administrative and laboratory data to assess cumulative CA-AKI incidence.
VA primary care patients in 2013-2017 with recorded outpatient serum creatinine (Scr) and no history of chronic kidney disease≥stage 5.
Sociodemographics, comorbidities, medication use, and health care utilization.
Annual incidence of CA-AKI defined as a≥1.5-fold relative increase in Scr on either a subsequent outpatient Scr or inpatient Scr obtained within ≤24 hours of admission.
We calculated the relative change in Scr within 12 months of an outpatient Scr value. A Cox model was used to estimate the association between CA-AKI and baseline characteristics, accounting for repeated measurements.
Of approximately 2.5 million eligible veterans each year, the cumulative incidence of CA-AKI was approximately 2% annually. Only 27% of CA-AKI was detected at hospital admission. In adjusted analyses, high health care utilization, chronic illness, cancer, rural location, female sex, and use of renin-angiotensin aldosterone system inhibitors or diuretics were associated with increased CA-AKI risk (all, HR>1.20).
Limited generalizability of results outside a veteran population, lack of a standardized definition for CA-AKI, and possibility of surveillance bias and misclassification.
CA-AKI affects 1 of every 50 US veterans annually. With less than a third of CA-AKI observed in the inpatient hospital setting, reliance on inpatient evaluation of AKI suggests significant underrecognition and missed opportunities to prevent and manage the long-term consequences of AKI.
Background
Chronic kidney disease (CKD) is a common condition with adverse health outcomes addressable by early disease management. The impact of the COVID-19 pandemic on care utilization for the CKD ...population is unknown.
Objective
To examine pandemic CKD care and identify factors associated with a high care deficit.
Design
Retrospective observational study
Participants
248,898 insured individuals (95% Medicare Advantage, 5% commercial) with stage G3–G4 CKD in 2018
Main Measures
Predicted (based on the pre-pandemic period of January 1, 2019–February 28, 2020) to observed per-member monthly face-to-face and telehealth encounters, laboratory testing, and proportion of days covered (PDC) for medications, evaluated during the early (March 1, 2020–June 30, 2020), pre-vaccine (July 1, 2020–December 31, 2020), and late (January 2021–August 2021) periods and overall.
Key Results
In-person encounters fell by 24.1% during the pandemic overall; this was mitigated by a 14.2% increase in telehealth encounters, resulting in a cumulative observed utilization deficit of 10% relative to predicted. These reductions were greatest in the early pandemic period, with a 19.8% cumulative deficit. PDC progressively decreased during the pandemic (range 9–20% overall reduction), with the greatest reductions in hypertension and diabetes medicines. CKD laboratory monitoring was also reduced (range 11.8–43.3%). Individuals of younger age (OR 1.63, 95% CI 1.16, 2.28), with commercial insurance (1.43, 95% CI 1.25, 1.63), residing in the Southern US (OR 1.17, 95% CI 1.14, 1.21), and with stage G4 CKD (OR 1.21, 95% CI 1.17, 1.26) had greater odds of a higher care deficit overall.
Conclusions
The early COVID-19 pandemic resulted in a marked decline of healthcare services for individuals with CKD, with an incomplete recovery during the later pandemic. Increased telehealth use partially compensated for this deficit. The downstream impact of CKD care reduction on health outcomes requires further study, as does evaluation of effective care delivery models for this population.
Patients hospitalized with AKI have higher subsequent risks of heart failure, atherosclerotic cardiovascular events, and mortality than their counterparts without AKI, but these higher risks may be ...due to differences in prehospitalization patient characteristics, including the baseline level of estimated glomerular filtration rate (eGFR), the rate of prior eGFR decline, and the proteinuria level, rather than AKI itself.
Among 2177 adult participants in the Chronic Renal Insufficiency Cohort study who were hospitalized in 2013-2019, we compared subsequent risks of heart failure, atherosclerotic cardiovascular events, and mortality between those with serum creatinine-based AKI (495 patients) and those without AKI (1682 patients). We report both crude associations and associations sequentially adjusted for prehospitalization characteristics including eGFR, eGFR slope, and urine protein-creatinine ratio (UPCR).
Compared with patients hospitalized without AKI, those with hospitalized AKI had lower eGFR prehospitalization (42 versus 49 ml/min per 1.73 m 2 ), faster chronic loss of eGFR prehospitalization (-0.84 versus -0.51 ml/min per 1.73 m 2 per year), and more proteinuria prehospitalization (UPCR 0.28 versus 0.16 g/g); they also had higher prehospitalization systolic BP (130 versus 127 mm Hg; P < 0.01 for all comparisons). Adjustment for prehospitalization patient characteristics attenuated associations between AKI and all three outcomes, but AKI remained an independent risk factor. Attenuation of risk was similar after adjustment for absolute eGFR, eGFR slope, or proteinuria, individually or in combination.
Prehospitalization variables including eGFR, eGFR slope, and proteinuria confounded associations between AKI and adverse cardiovascular outcomes, but these associations remained significant after adjusting for prehospitalization variables.
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