#3410 Guideline adherence in primary and nephrology care for older patients with advanced chronic kidney disease and the association with social and clinical characteristics

Le résumé fourni par la source

Abstract Background and Aims Previous studies indicate that 40% of patients with advanced chronic kidney disease (CKD), a proportion that increases with age, are managed in primary care despite meeting referral criteria. Older patients are more likely to have stable kidney function or may find hospital visits burdensome. We aimed to describe the proportion of older patients with advanced CKD receiving guideline-adherent care in primary and nephrology care, and describe how clinical characteristics and social determinants of health are associated with guideline adherence. Ultimately, we aim to assess whether primary care can be a suitable setting for managing subgroups of older CKD patients and adequately addressing their needs. Method This dynamic, population-based cohort study, used routine health care data of general practitioner (GP) practices and hospitals within the Extramural Leiden University Medical Center Academic Network (ELAN), linked to individual-level registry data from Statistics Netherlands. We included adults aged ≥65 years with incident or prevalent CKD (eGFR ≤30 ml/min/1.73 m2, confirmed by two measurements taken ≥90 days apart) between 2015 and 2023. Follow-up continued until death, kidney replacement therapy initiation, end of study (01-01-2023) or deregistration from a participating GP. Patients were categorized as managed in primary or nephrology care based on diagnosis-treatment combinations. We used descriptive statistics to assess the proportion of patients in each care setting and adherence to CKD guidelines, stratified by clinical characteristics and social determinants of health. Results We enrolled 1647 patients, with a median follow-up of 2.25 years; 1194 were managed exclusively in primary care and 453 (part of) follow-up in nephrology care. The mean age was 82 ± 9 years (83 ± 9 in primary care vs 79 ± 8 in nephrology care), with a median eGFR of 26 [22; 28] ml/min/1.73 m2. Of these, 973 patients had at least 15 months of follow-up in primary or nephrology care, allowing for guideline-adherence assessment. Patients with shorter follow-up were more likely to be female (55% vs 46%), older (83 ± 9 vs 81 ± 8 years), and classified as frail (30% vs 21%). Differences in adherence to quality indicators were observed between the care settings (see Fig. 1), with nephrology care showing higher adherence to kidney function monitoring (≥2 measurements per year: 68% vs 83%), annual testing of albuminuria (45% vs 65%), hemoglobin (74% vs 87%), LDL (49% vs 60%), and HbA1c (50% vs 65%), as well as higher prescription rates of renin-angiotensin-aldosterone system inhibitor (RAASi) (72% vs 77%). Annual blood pressure measurement and avoidance of NSAIDs were similar across care settings (60% vs 57% and 94% vs 94%, respectively). In both care settings, we observed lower guideline adherence for women across all indicators and a decrease in adherence with age, except for eGFR monitoring in nephrology care and blood pressure monitoring in both care settings. In primary care, patients with diabetes mellitus were more likely to receive guideline-adherent care compared to those without diabetes, with a similar trend observed for patients with hypertension, albeit to a lesser extent. No differences were found between ethnic and socioeconomic groups, or in relation to eGFR and frailty. Conclusion The majority of older patients with advanced CKD are managed in primary care, where guideline adherence is generally acceptable, but less strictly followed than in nephrology care. Among patients with diabetes or hypertension, who are treated in structured care pathways, adherence is higher, suggesting that similar proactive and structured approaches could enhance CKD care. Given the life expectancy and treatment goals of older patients, CKD management should prioritize individual needs and quality of life over strict guideline adherence. Future research should explore whether outcomes, including CKD progression, quality of life and healthcare costs, differ between patients managed in primary and nephrology care.

Ce résumé expose les affirmations des auteurs. BNTIC ne l’interprète pas comme une validation indépendante des résultats.