Opportunities for improving the care of patients with chronic renal insufficiency: Current practice patterns

There are between 2 and 13 million Americans with chronic kidney disease (C KD). Recent reports suggest that their treatment is currently suboptimal. T o further investigate this issue, patterns of practice for the treatment of patients with CKD who were enrolled in a large health maintenance organiza tion in New Mexico were analyzed. Among the >200,000 patients who were enro lled in the health maintenance organization between 1994 and 1997, a cohort of 1658 patients who exhibited at least two gender-specific, elevated crea tinine concentrations (Cr), separated by at least 90 d, were identified. Th e proportions of patients with Cr values of <2.0, 2.0 to 2.9, 3.0 to 3.9, a nd <greater than or equal to>4.0 mg/dl were 73, 17, 3, and 7%, respectively . The majority of patients were treated by a primary care physician until C r values reached 3.0 mg/dl, at which time a nephrologist was consulted. Car e tended to be transferred to the nephrologist when the Cr reached 4.0 mg/d l. Only 7.4% of patients received erythropoietin (EPO). Use of EPO increase d as Cr increased. EPO was unlikely to be prescribed unless the patient had visited a nephrologist. Fewer than one half of all patients with CKD and f ewer than 20% of patients with CKD with Cr values of greater than or equal to4.0 mg/dl received an angiotensin-converting enzyme inhibitor (ACEI). Nep hrologists were not more likely to prescribe ACEI than were primary care ph ysicians. Diabetic patients were more likely to receive ACEI than were nond iabetic patients, but ACEI use was quite low even among diabetic patients w ith CKD. The average number of hospitalizations per patient-year increased as Cr increased and was more than twice as high for patients with Cr values of greater than or equal to4.0 mg/dl, compared with those with Cr values o f <2.0 mg/dl. The reasons for hospitalization were more likely to be relate d to comorbidities than to CKD itself, however. There are many opportunitie s to improve the care of patients with CKD. Better adherence to practices k nown to be of clinical benefit for patients with CKD not only will improve patient outcomes but also may reduce the costs of care. Providers, policy-m akers, and payers should view CKD as a major public health problem and init iate innovative programs to address this growing patient population.