Screening and Recognition of Chronic Kidney Disease in VA Health Care System Primary Care Clinics

Abstract

BackgroundThe successful implementation of interventions targeted to improve kidney health requires early identification of CKD which involves screening at-risk populations as well as recognizing CKD. We aim to determine CKD screening and recognition rates, factors associated with these rates, and evaluate the effect of CKD awareness on delivery of care.MethodsA retrospective cohort study of veterans enrolled with Veterans Integrated Service Network 17 who had hypertension (HTN) and/or diabetes (DM) and were seen at least twice in primary care clinics within 18 months. The final cohort of 270,170 patients (52% HTN, 5% DM, and 44% both) was examined for serum creatinine/eGFR, urine protein/albumin, International Classification of Diseases (ICD) codes for CKD, and nephrology referral. CKD was defined as eGFR <60 ml/min per 1.73 m2 and/or urine albumin-creatinine ratio (uACR) >30 mg/g at least twice 90 days apart. Clinical covariates, HTN control, and prescription rates of renal prudent medications and nonsteroidal anti-inflammatory drugs (NSAIDs) were assessed.ResultsOverall, 254,831 (94%) patients had either eGFR, urine protein/albumin, or both. However, screening for protein/albuminuria was low (56%), particularly in patients with isolated HTN (35%). Of 254,831 patients, 92,900 (36%) had laboratory evidence of CKD and, of these, 40,586 (44%) were recognized to have CKD by ICD code and/or nephrology referral. CKD due to presence of uACR criteria alone had the lowest recognition (19%) as compared with CKD due to eGFR criteria (44%) or both (67%). Frequency of emergency room visits, hospitalization, and cardiac and endovascular procedures requiring contrast had the highest odds and races other than white had the lower odds of screening. In contrast, CKD recognition was high in races other than white and increased with worsening eGFR and increasing uACR. In screened and recognized CKD, prescription was higher for angiotensin inhibitors, statins, and diuretics, and was lower for NSAIDs.ConclusionsAlthough overall CKD screening rate was high, screening of protein/albuminuria in isolated HTN and overall recognition of CKD was low in at-risk veterans. Increased recognition was associated with a favorable prescription rate for renal prudent medications.