Friday, November 29, 2013

New data on quality of care and cardiovascular outcomes in diabetes

A recent report from The Netherlands analyzed the relationship between quality of care in diabetes and long-term cardiovascular outcomes. The authors had access to a large database of 10,058 patients with type 2 diabetes. They looked at a number of predictors including whether the patients were treated for high blood glucose, high cholesterol, high blood pressure and albuminuria (a marker of incipient kidney damage in diabetes). Over 3 years, treatment of high lipids and albuminuria were each associated with about a 25% reduction in cardiovascular events and all-cause mortality (HR = 0.77, 0.67–0.88; HR = 0.75, 0.59–0.94). Glucose lowering treatment status was associated with a similar effect, but only in patients with an elevated HbA1c level at baseline (HR = 0.72, 0.56–0.93). (Oddly, treatment of hypertension was not associated with better outcomes.)

This report is important for several reasons. First, it serves to validate that we are probably measuring the right things when we do quality improvement based on the Medicare 5-star program or other quality measurement initiatives based on the HEDIS criteria.

Second, it points out how soon we get the payoff. The effect of high quality management is apparent within 3 years, probably sooner. (Unfortunately, the report does not provide information on exactly when the effects were seen, only that they occurred over the course of the 3-year study.) You don't need to wait 20 years to see the benefits in terms of mortality, morbidity and costs.

Third, this study emphasizes the big opportunity represented by untreated albuminura. Primary care in the US is generally fair to good at tracking A1C and cholesterol in diabetes patients, but our track record with monitoring and managing albuminuria is much worse. So, a big take-home message for me is to work hard on urine monitoring.

Sidorenkov G, Voorham J, de Zeeuw D, Haaijer-Ruskamp FM, Denig P (2013) Do Treatment Quality Indicators Predict Cardiovascular Outcomes in Patients with Diabetes? PLoS ONE 8(10): e78821. doi:10.1371/journal.pone.0078821

Friday, November 22, 2013

Screening Asymptomatic Adults for Chronic Kidney Disease (CDK)

This month has seen a scuffle of sorts between the American College of Physicians (ACP), representing America's internists and with a viewpoint largely derived from the primary care providers who make up much of its membership, and the American Society of Nephrology (ASN), a group of sub-specialty kidney physicians. It started when the ACP released one of their hallmark practice guidelines. This one was about screening and management of early stage chronic kidney disease (CKD) and came to the conclusion that screening of asymptomatic adults for CKD was not warranted, largely because it has never been shown to be effective and there are clearly potential downsides. (ACP guidelines are not just evidence-based, they are downright evidence-driven.) The ASN took exception to this guideline and published a flurry of press releases calling for screening.

Full disclosure: I am a Fellow of the ACP and a big proponent of evidence-based medicine. However, I don't have a horse in this race, other than my desire to not see CKD become an inter-specialty football.) The ASN is right that lots of CKD is not being diagnosed or managed to prevent progression, but neither screening nor ignoring the problem may be the best way forward.

In my experience setting up chronic disease registries and decision support systems, 40-50% of the people in primary care with undiagnosed CKD have had an abnormal blood or urine test in the past two years. These tests weren't done for screening, and although abnormal, they didn't trigger a diagnosis by the provider. (The reasons for this are many, including the tricky nature of the serum creatinine in older adults and uncertainty about the diagnostic criteria on the part of the providers.) So, rather than go out and screen a new batch of folks and figure out how to get them plugged into care, the first thing to do is identify all the patients already in the practice with evidence of CKD and start managing them. These patients are currently under care for something, so we don't have to find them a provider. What we do need to do is build systems to identify them, bring them to the attention of their providers, and support them and the practices as they develop plans to prevent progression.

Very few practices have the tools to manage this job now. Screening a whole new population of CKD patients will just make the situation worse until we have systems in place to not only identify these patients, but engage them and their providers in the long-term process of averting, delaying, and mitigating progression to renal failure. Although Electronic Medical Records (EMRs) can help, none of the currently available EMR systems has the capacity to manage chronic care in a way that doesn't create a lot of extra work for the practice. Happily, there are systems that can do this at low cost and with good results, including documented reductions in overall utilization.

So, rather than argue about whether we should find more patients with CKD, let's work together to take better care of the patients we already have with undiagnosed and unmanaged disease.

You can read the ACP's Clinical Practice Guidelines in Annals of Internal Medicine.

Also see the ASN's Press Release here.