UNDERSTANDING AND IMPROVING THE QUALITY OF PRIMARY CARE FOR PATIENTS WITH CHRONIC KIDNEY DISEASE

Abstract

Background: International guidelines provide recommendations for early chronic kidney disease care. This thesis was completed to 1) measure the quality of chronic kidney disease care and identify gaps, 2) identify reasons why patients do not receive recommended care, and 3) determine if these guideline-recommended practices are associated with better patient outcomes. Methods: Population-based cohort studies were conducted for studies 1, 3 and 4. Using consensus-based indicators, study 1 quantified the quality of care for patients with early chronic kidney disease. Study 2 was a qualitative descriptive study eliciting primary care physicians’ perceived enablers and barriers to follow-up laboratory testing to confirm chronic kidney disease. Study 3 assessed the association between non-steroidal anti-inflammatory drug (NSAID) use versus non-use and adverse clinical outcomes among older adults. Study 4 assessed whether routine serum creatinine and potassium monitoring (versus no monitoring) following angiotensin converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) initiation among older adults associated with better outcomes. Results: In study 1, most recommendations were being followed; however, some care gaps were identified. For example, half of the patients with initial abnormal kidney test results did not receive follow-up tests. This finding prompted study 2, where enablers and barriers to this practice were identified. Providers were aware that they should be ordering follow-up tests and had the resources to do so. However, some providers perceived this practice as low priority. In study 3, NSAID use was associated with a higher risk of complications. In study 4, routine ACEi / ARB monitoring did not prevent adverse outcomes. Conclusions: This thesis provides a better understanding of care gaps for patients with early chronic kidney disease in Ontario, and reasons for one of these care gaps. This research also provides evidence to help strengthen guideline recommendations (NSAID avoidance) or refute them (ACEi / ARB monitoring).