TY - JOUR
T1 - Effects of Higher Quality of Care on Initiation of Long-term Dialysis in Patients With CKD and Diabetes
AU - Wu, Hon Yen
AU - Fukuma, Shingo
AU - Shimizu, Sayaka
AU - Norton, Edward C.
AU - Tu, Yu Kang
AU - Hung, Kuan Yu
AU - Chen, Mei Ru
AU - Chien, Kuo Liong
AU - Fukuhara, Shunichi
N1 - Funding Information:
We thank Dr Joseph Green for advice on an earlier version of the manuscript. The interpretation and conclusions presented in this study are those of the authors and do not represent the views of the NHI Administration or the National Health Research Institutes in Taiwan. Support: This study was supported by research grants to Dr Wu from the Ministry of Science and Technology , Taiwan (MOST 103-2314-B-418-003-MY2 ); the National Health Research Institutes , Taiwan ( NHRI-EX105-10510PC , NHRI-EX106-10510PC ); and the Far Eastern Memorial Hospital , New Taipei City, Taiwan ( FEMH 103-2314-B-418-003-MY2 , FEMH-2016-C-027 , FEMH -EX106-10510PC ). The funders had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication. Financial Disclosure: The authors declare that they have no other relevant financial interests. Contributions: Research idea and study design: H-YW, SFukuma, K-LC, SFukuhara; data acquisition: H-YW, M-RC, Y-KT, K-YH, K-LC; data analysis/interpretation: H-YW, SFukuma, SS, ECN, K-LC, S-Fukuhara; statistical analysis: H-YW, SFukuma, ECN, M-RC; supervision and mentorship: ECN, K-YH, K-LC, SFukuhara. Each author contributed important intellectual content during manuscript drafting or revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved. Peer Review: Evaluated by 2 external peer reviewers and an external methods reviewer, with editorial input from a Statistics/Methods Editor, an Associate Editor, and Editor-in-Chief Feldman.
Publisher Copyright:
© 2017
PY - 2017/11
Y1 - 2017/11
N2 - Background The burden of diabetes-related chronic kidney disease (CKD) on individuals and society is increasing, shifting attention toward improving the quality of care for patients with CKD and diabetes. We assessed the quality of CKD care and its association with long-term dialysis, acute kidney injury (AKI), and death. Study Design Retrospective cohort study (2004-2011). Setting & Participants Adults in Taiwan with incident CKD enrolled in the Longitudinal Cohort of Diabetes Patients. Predictors 3 CKD-care quality indicators based on medical and pharmacy claims data were studied: prescription of renin-angiotensin system inhibitors, testing for proteinuria, and nutritional guidance. Each was examined individually, and all were summed into an overall quality score. Outcomes The primary outcome was initiation of long-term dialysis therapy. Secondary outcomes were hospitalization due to AKI and death from any cause. Measurements Using instrumental variables related to the quality indicators to minimize both unmeasured and measured confounding, we fit a 2-stage residual inclusion model to estimate HRs and 95% CIs for each outcome. Results Among the 63,260 patients enrolled, 43.9% were prescribed renin-angiotensin system inhibitors, 60.6% were tested for proteinuria, and 13.4% received nutritional guidance. During a median follow-up of 37.9 months, 1,471 patients started long-term dialysis therapy, 2,739 patients were hospitalized due to AKI, and 4,407 patients died. Higher overall quality scores were associated with lower hazards for long-term dialysis in instrumental variable analyses (HR of 0.62 [95% CI, 0.40-0.98] per 1-point greater score) and hospitalization due to AKI (HR of 0.69 [95% CI, 0.50-0.96] per 1-point greater score). The hazard for all-cause death was nonsignificantly lower (HR of 0.80 [95% CI, 0.62-1.03] per 1-point greater score). Limitations Potential misclassification and uncontrolled confounding by indication. Conclusions Our findings suggest potential opportunities to improve long-term outcomes among patients with diabetes and CKD by improving the quality of their CKD care.
AB - Background The burden of diabetes-related chronic kidney disease (CKD) on individuals and society is increasing, shifting attention toward improving the quality of care for patients with CKD and diabetes. We assessed the quality of CKD care and its association with long-term dialysis, acute kidney injury (AKI), and death. Study Design Retrospective cohort study (2004-2011). Setting & Participants Adults in Taiwan with incident CKD enrolled in the Longitudinal Cohort of Diabetes Patients. Predictors 3 CKD-care quality indicators based on medical and pharmacy claims data were studied: prescription of renin-angiotensin system inhibitors, testing for proteinuria, and nutritional guidance. Each was examined individually, and all were summed into an overall quality score. Outcomes The primary outcome was initiation of long-term dialysis therapy. Secondary outcomes were hospitalization due to AKI and death from any cause. Measurements Using instrumental variables related to the quality indicators to minimize both unmeasured and measured confounding, we fit a 2-stage residual inclusion model to estimate HRs and 95% CIs for each outcome. Results Among the 63,260 patients enrolled, 43.9% were prescribed renin-angiotensin system inhibitors, 60.6% were tested for proteinuria, and 13.4% received nutritional guidance. During a median follow-up of 37.9 months, 1,471 patients started long-term dialysis therapy, 2,739 patients were hospitalized due to AKI, and 4,407 patients died. Higher overall quality scores were associated with lower hazards for long-term dialysis in instrumental variable analyses (HR of 0.62 [95% CI, 0.40-0.98] per 1-point greater score) and hospitalization due to AKI (HR of 0.69 [95% CI, 0.50-0.96] per 1-point greater score). The hazard for all-cause death was nonsignificantly lower (HR of 0.80 [95% CI, 0.62-1.03] per 1-point greater score). Limitations Potential misclassification and uncontrolled confounding by indication. Conclusions Our findings suggest potential opportunities to improve long-term outcomes among patients with diabetes and CKD by improving the quality of their CKD care.
KW - acute kidney injury (AKI)
KW - chronic kidney disease (CKD)
KW - diabetes
KW - Diabetic kidney disease
KW - disease progression
KW - end-stage renal disease (ESRD)
KW - healthcare quality of care
KW - incident dialysis
KW - instrumental variable analysis
KW - quality indicators
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U2 - 10.1053/j.ajkd.2017.05.020
DO - 10.1053/j.ajkd.2017.05.020
M3 - Article
C2 - 28764919
AN - SCOPUS:85026488112
SN - 0272-6386
VL - 70
SP - 666
EP - 674
JO - American Journal of Kidney Diseases
JF - American Journal of Kidney Diseases
IS - 5
ER -
