Quality of Chronic Kidney Disease Management in Canadian Primary Care

This cross-sectional study assesses chronic kidney disease management in Canadian primary care practices to identify care gaps to guide development and implementation of national quality improvement initiatives.


Introduction
Chronic kidney disease (CKD) is a frequently treated condition at health care systems, both globally and within Canada, with a prevalence of approximately 10% in the general population. [1][2][3] Most patients with CKD are at low risk of progression to end-stage kidney disease (ESKD) and are ideally managed in primary care settings. 4 Organizations such as Kidney Disease: Improving Global Outcomes, the UK National Institute for Health and Clinical Excellence, 5 and the Canadian Society of Nephrology 6 provide recommendations regarding the management of patients with CKD to reduce the risk of adverse consequences of ESKD and cardiovascular disease. Despite these guidelines, variability in care continues. [7][8][9] Regular quality audits at local, provincial or state, and national levels could identify variations in care and inform resource allocation, primary care physician training, education, and other quality improvement activities. 10,11 Furthermore, assessment benchmarks for quality are the first step to evaluating innovations aimed at creating high-functioning and sustainable health systems. 12 A few studies 7,9,13 have examined quality of care for patients with CKD in primary care settings using provincial (regional) data. To our knowledge, no studies have examined pan-Canadian performance in meeting quality-of-care indicators for CKD management in primary care, as has been done in other settings. [14][15][16][17] National chronic disease surveillance systems, such as the Canadian Primary Care Sentinel Surveillance Network (CPCSSN), have been designed to facilitate national quality improvement studies to improve chronic disease management. [15][16][17][18] Understanding data from Canadian primary care may indicate gaps in care processes and demonstrate a proof of concept for the use of CPCSSN data to inform targeted priorities for improvement in management of patients with chronic diseases.
The key objectives of this study were to define the current state of CKD management in Canadian primary care practices based on existing guidelines and to stratify key results by population demographics.

Design and Participants
This cross-sectional study used a national database (CPCSSN data) to develop a cohort of patients with CKD managed in primary care from January 1, 2010, to December 31, 2015 (Figure 1). Data analysis was performed from August 8, 2018, to July 31, 2019. We examined prevalent CKD (defined based on expert guideline criteria) 19 during the study period and determined quality indicators for CKD care in patients who met the case criteria. Patients were identified as having CKD if they had at least 2 estimated glomerular filtration rate (eGFR) measurements less than 60 mL/min/1.73 m 2 within a period of at least 3 months but not more than 18 months (Figure 2). Only those with moderate-toadvanced CKD (stages [3][4][5] were eligible. Patients with ESKD undergoing dialysis or who had received Research Ethics Committee. The CPCSSN has received a waiver of the requirement to obtain individual patient consent to include their deidentified data in its data set unless they have specifically opted out.

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As data custodians, sentinels permit this use of the data on behalf of their patients.

Setting and Data Sources
The CPCSSN is composed of 13 regional networks that form a national disease surveillance system that collects primary care data from 9 of the 13 provinces and territories in Canada. 20   A sample timeline of the decision process followed to identify patients with CKD (defined as having Ն2 estimated glomerular filtration rate [eGFR] measurements <60 mL/min per 1.73 m 2 within at least 3 months but not more than 18 months) in the Canadian Primary Care Sentinel Surveillance Network data repository. Qualifying eGFR indicates an eGFR value less than 60 mL/min per 1.73 m 2 ; blocked phase, period of 90 days after the first qualifying eGFR measurement at which no second eGFR measurement was considered confirmatory of CKD; qualifying phase, period of 3 to 18 months after the first qualifying eGFR measurement that a second eGFR measurement confirms CKD and qualifies the patient to be included in the study; and follow-up period, 1 year after confirmation of CKD to assess the use of appropriate medications.

Definition and Derivation of Quality Indicators of CKD Management
Quality indicators for CKD care in primary care practices were derived from the published expert guideline and those developed by the Canadian experts. The Canadian Society of Nephrology published a guideline for the management of CKD 2 years before the onset of this study in 2008. 19 We examined and adapted 12 quality indicators based on previously published data and guidelines. 7,19 The indicators were categorized under the domains of detection and recognition of CKD, testing and monitoring of kidney function, use of recommended medications, monitoring after initiation of treatment with angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs), management of blood pressure, and monitoring for glycemic control (Figure 3). The cutoff for being considered as having achieved each quality-of-care indicator was 75% of patients who reached the target during the study period.

Covariates
To understand the variability in quality indicators, we divided the cohort of patients with CKD into 4 categories for subgroup analysis using validated CPCSSN case definitions: patients without hypertension or diabetes, patients with hypertension only, patients with diabetes only, and patients with hypertension and diabetes. 22 For further analysis, we stratified quality indicator data by CKD stage (stages 3-5), age category, and sex. All variables were extracted from patient EMRs available in the CPCSSN data repository.

Statistical Analysis
Patient demographic and clinical characteristics were tabulated descriptively using proportions or means as appropriate. The proportion of patients who met the CKD management criteria for the quality indicators were calculated for the overall cohort and by comorbid subgroup, with χ 2 tests of the differences between subgroups indicating statistically significant differences in quality of care.  Monitoring for glycemic control Patients with an eGFR <60 mL/min per 1.73 m 2 and diabetes receiving an HbA 1c test within the first and second years 12 Patients with an eGFR <60 mL/min per 1.73 m 2 who achieved a target BP of ≤140/90 mm Hg 10 Patients with an eGFR <60 mL/min per 1.73 m 2 who also had evidence of albuminuria and/or diabetes and achieved a target BP of ≤130/80 mm Hg

11
The 12 quality indicators for patients with chronic kidney disease (CKD) in primary care used in the study are shown. The 12 indicators were categories under the domains of detection and recognition of CKD, testing and monitoring of kidney function, use of recommended medications, monitoring after initiation of treatment with angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs), management of blood pressure, and monitoring for glycemic control. BP indicates blood pressure; eGFR, estimated glomerular filtration rate; HbA 1c , glycated hemoglobin; and UACR, urine albumin to creatinine ratio.
We used binomial regression models to identify key demographic characteristics associated with not receiving specified care. We reported the estimated risk ratio (RR) and corresponding 95% CI for each association for the variables assessed and presented these graphically using forest plots.
Missing data were handled by listwise deletion because the missingness was assumed to be random.
All analyses were performed using Stata, version 14.2 (StataCorp). 23 A 1-sided P < .05 was considered to be statistically significant.

Baseline Demographics
The

Overview of Quality of CKD Management
Only 4 quality indicators were successfully met in 75% or more of the cohort ( Table 2 and   of albuminuria], use of recommended medications, and appropriate monitoring after initiation of treatment with ACEIs or ARBs) were not met in at least 75% of the cohort.

Detection and Recognition of CKD and Monitoring of Kidney Function
Overall, 6529 patients with CKD (18.4%) received follow-up urine albumin to creatinine ratio (UACR) testing within 6 months of CKD diagnosis. In subgroup analysis, detection was significantly less

Variations Across Disease Stage, Comorbid Status, Age, and Sex
Across CKD stages, delivery of guideline-concordant care was more common with each progressive stage with the exception of stage 5 (eTable 1 in the Supplement

Factors Associated With Lower Achievement of Quality Indicators
The factors associated with not receiving a UACR test within 6 months and 18 months of a qualifying eGFR are shown in eFigure 2 and eFigure 3 in the Supplement. Factors associated with not being prescribed a statin are given in eFigure 4 in the Supplement, for not being prescribed ACEIs or ARBs for patients who had evidence of proteinuria and/or diabetes in eFigure 5 in the Supplement, and for not receiving a blood pressure measurement and achieving targets in eFigures 6-9 in the Supplement.

Variations Across Physician Characteristics
Overall, no association between age or sex (or a combination) of physician and adherence to guidelines was found (eTable 4 in the Supplement).

Discussion
In this national study of more than 46 000 Canadian individuals with stage 3 to 5 CKD managed in primary care, we identified gaps in the quality of CKD care related to monitoring and testing for albuminuria as well as use of recommended medications to reduce risk of progression to ESRD and prevent cardiovascular events. To our knowledge, this is the first study to examine quality indicators for CKD management in Canadian primary care at a national level and to study associations of variance.
Overall We found that the presence of stage 5 CKD and older ages were associated with a lower likelihood of meeting the quality indicators. There are several possible reasons why these gaps may exist. First, these findings may relate to clinical decisions that reflect increased patient complexity or a more supportive approach to care. Multimorbidity is common in older adults, 24 meaning that single-disease approaches to guiding treatment may be inappropriate and potentially harmful if treatment targets are applied indiscriminately while ignoring medical complexity. For example, it may be appropriate to not prescribe medications for a specific individual given their multimorbidity even though it may seem appropriate based on guidelines. 25,26 The reasons are complex and include drugdrug and drug-disease interactions, a patient's treatment priorities, the overall burden of medical care, and limited lifespan benefit. Understanding the difference between appropriate variance and inappropriate (low-quality) care can inform future quality improvement initiatives. Evidence-based medicine is predicated on patient-centered decision-making, which is one of the core mechanisms by which primary care achieves better population outcomes. In this model, individuals are free to choose not to engage with recommended care, and it is valid for a patient to make a choice that is consistent with their values despite incongruence with guideline recommendations.
After stratification by stage of CKD and sex, with the general exception of stage 5, each progressive stage of CKD was associated with increased conformity to guideline-recommended care different disciplines (eg, women receive less guideline-concordant care for myocardial infarction 27 and heart failure 28 ). Specific to CKD, the sex differences associated with heart failure described in the literature relate to disease epidemiology, prognosis, and progression. 29,30 The novel finding of sex differences in quality of care for CKD is an area for future study. Possible implications for sex differences in disease management could include the development of new approaches to disease identification and modified training materials for medical practitioners. 11,30 A major implication to practice and quality improvement initiatives is that the management of CKD varied across indicators. The worst-performing indicator and a finding of significant concern was that only 18.4% of patients received a follow-up UACR test within 6 months of CKD diagnosis. The association of older age with assessed variables provides direction for the development of quality improvement interventions. One possible explanation is that some health care professionals may not consider an eGFR measurement within the range of stage 3A CKD to indicate a risk of disease progression to ESKD in older people. They might consider such a measurement as reflecting the physiologic changes associated with aging because CKD seldom progresses in the absence of albuminuria. Thus, some experts have asked for an age-calibrated classification for CKD. 31 The other quality indicator at variance with guideline concordance was follow-up albuminuria tests when indicated, which was not well met. Associations for not receiving this test included older age and rural residency, the latter reflecting previous findings that patients with CKD living in rural settings may receive lower quality of care than patients living in urban settings. 32 The rural-urban health disparity has been the subject of many reports 33,34  with not achieving a target blood pressure were older age, stage 3A CKD, and living in rural areas.
Older age is associated with increased risk of comorbidities; therefore, elevated blood pressure is common. Treatment of hypertension with pharmacotherapy in older age is also associated with an increased risk of falls and serious injury, and treatment thresholds are therefore a balance of risks and benefits requiring a more individualized approach to care. 35 The finding that those with stage 3A CKD were unlikely to achieve a target blood pressure remains unexplained. Our finding that living in rural areas was associated with nonconformance with target blood pressure levels is supported by results from a population-based study 9 that found that patients with diabetes and CKD living in rural or remote parts of Alberta, Canada, were less likely to meet process-based outcomes (eg, glycated hemoglobin and albuminuria measurements, use of recommended medications) than were their urban counterparts. These findings underscore the importance of targeted intervention to address geographic disparities in CKD care. For instance, the use of electronic consultations (asynchronous electronic communication between physicians) was found to improve access to specialist advice in remote communities in Canada. 36 In addition to the patient-related factors (demographic, clinical, and laboratory) outlined in our results, we specifically examined physician factors and found no association between age or sex (or a combination) of physician and adherence to guidelines. It is important to recognize the wider context of physician factors in implementation of guideline recommendations, which has implications in understanding concordance and variation. 37 For example, the volume of guideline recommendations for primary care is increasing at a rate that is not sustainable for implementation.

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For a primary care physician, it would take 7 hours a day to follow all preventive recommendations and 10 hours a day to follow recommendations for 10 chronic diseases. These data are based on an assessment in the mid-2000s, and guideline proliferation continues. 37,38 How should a primary care physician prioritize smoking cessation vs urine protein analysis? Primary care physicians may prioritize patients according to which factor seems likely to be most associated with patients' outcomes and focus on quality improvement initiatives that are most important for population health improvement. This approach may improve implementation and adoption of guidelines in general.
This study builds on a previous study 39 that used data from CPCSSN to estimate the prevalence of CKD being managed in primary care practices across Canada. This current work provides an in-depth assessment of the current practice pattern and variations in care for CKD to understand areas of appropriate and inappropriate variation within the context of multimorbidity, patientcentered care, and primary care service delivery to support quality improvement that is most meaningful for patients.

Limitations
This study had several limitations. We limited our analysis to data from patients with moderate to advanced stages of CKD (stages 3-5) because patients with early stages of CKD cannot be readily identified based on eGFR measurements alone. As a result, we were not able to capture the quality of care received by patients with early-stage CKD, which is often asymptomatic. Another limitation of the study relates to the representativeness of the cohort to the general Canadian population. Our cohort tended to be older than the general Canadian population and included slightly more women than men than in the general population. Moreover, data in the CPCSSN repository are based on information available from the source EMRs; gaps in data quality (particularly related to completeness and capture) may have underestimated actual clinical performance associated with the indicators considered in this study, which has limited our ability to use other CKD markers, such as dipstick proteinuria. Furthermore, the nature of the data made it difficult to establish temporality with clinical situations that could limit the application of some of the quality indicators in practice, for example, the use of ACEIs or ARBs in the context of hyperkalemia and/or hypotension.
In addition, even though the Canadian Society of Nephrology guideline for the management of CKD was published 2 years before the onset of this study, differential uptake of its recommendations among primary care physicians could be fraught with inherent complexities. Physician-related factors (eg, age, sex, years in practice, time, and resources), patient factors, and practice environment contextual factors (academic vs community based, rural vs urban, and regulation) inform adoption of guidelines into practice. 40 Moreover, it is also widely recognized that lack of awareness of the availability of the guideline and familiarity with its details were common barriers to implementation in patient care. 41 These issues are relevant to the interpretation of our findings.
Some primary care physicians in Canada might not have been aware of the existence of the CKD management guideline, and this awareness might have come to them over time in their practice outside the scope of the study. Clinical practice guidelines are often produced by specialty societies, as was the CKD management guideline, and it would be challenging for primary care physicians to keep up to date and adopt all of the guidelines into practice. These data may provide an opportunity to engage with relevant primary care organizations in Canada, such as the College of Family Physicians of Canada and other primary care professional societies, to close the identified gaps and facilitate uptake of the guideline for optimal kidney care.
SUPPLEMENT. eFigure 1. Performance related to quality indicators eFigure 2. Associations for not receiving a UACR test within 6 months following the confirmation of CKD eFigure 3. Associations for not receiving a UACR test within 18 months following the confirmation of CKD eFigure 4. Associations for not being prescribed a statin at any time in the 1 year following the confirmation of CKD eFigure 5. Associations for not being prescribed an ACE inhibitor or ARB at any time in the 1 year following the confirmation of CKD eFigure 6. Associations for not receiving a blood pressure measurement at any time eFigure 7. Associations for not receiving a blood pressure measurement within six months of initial eGFR measurement eFigure 8. Associations for not achieving a target BP of Յ140/90mmHg, among those with blood pressure measure after CKD diagnosis eFigure 9. Associations for not achieving a target BP of Յ130/80mmHg, among those with confirmed CKD and evidence of albuminuria and/or diabetes eTable 1. Quality of care indicators for CKD, overall and by comorbid status, and disease stage eTable 2. Quality of care indicators for CKD, overall and by comorbid status and age categories eTable 3. Quality of care indicators for CKD, overall and by comorbid status, and sex eTable 4. Variations of quality of care indicators for CKD, across physician characteristics (age and gender)