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After controlling for these potential confounders, co-management was associated with monitoring tests, both for progression and for complications.Co-management was associated with higher rates of ACE/ARB prescription in stage 3 CKD, but not in stage 4 CKD.All outpatient vital signs were recorded in the EHR.Covariates such as socio-demographic data were collected during registration and updated periodically in the EHR.For stage 4 patients, we additionally examined annual serum parathyroid hormone test.We examined several potential confounders of the relationship between co-management and outcomes by first assessing association between the potential confounder and co-management.We conducted a retrospective cross-sectional analysis. Patients included in the study were adults who visited a PCP during 2009 with laboratory evidence of CKD in the preceding two years, defined as two estimated glomerular filtration rates (e GFR) between 15–59 m L/min/1.73 m separated by 90 days. To assess the relationship between nephrology co-management and quality of care, we conducted a retrospective cross-sectional analysis of electronic health record (EHR) data for patients with stage 3 and 4 CKD, comparing co-managed patients to solo managed patients.We assessed process measures (serum e GFR test, urine protein/albumin test, angiotensin converting enzyme inhibitor or angiotensin receptor blocker [ACE/ARB] prescription, and several tests monitoring for complications) and intermediate clinical outcomes (mean blood pressure and blood pressure control) and performed subgroup analyses by CKD stage. After receiving approval from the Partners Healthcare Human Research Committee and being granted waiver of consent, we electronically screened all patients who had at least one visit to a PCP at one of 12 primary care clinics in the Brigham and Women’s Primary Care Practice Based Research Network during 2009.
We hypothesized that PCP diagnosis of CKD could be related to, or on the causal pathway to, referral and so we examined the impact of adjusting for this variable in fully adjusted models.With a BP goal of 140/90 mm Hg, 71 % were under control and the likelihood of being under control was not associated with nephrology co-management.With a BP goal of 130/80 mm Hg, 45 % were under control and the likelihood of BP being under control was not associated with nephrology co-management.Co-management was associated with socio-demographic differences, particularly in stage 3 CKD patients for whom co-management was associated with younger age, male gender and minority race/ethnicity.Co-management was associated with diabetes, hypertension, and more frequent PCP visits.
Patients who were co-managed were more likely to receive an ACE/ARB prescription. In stage 4 patients, nephrology co-management was associated with a higher rate of one test monitoring for progression (urine protein/albumin), and tests monitoring for complications (serum hemoglobin, serum phosphorus, and serum parathyroid hormone), both before and after adjustment for potential confounders (Table Percentage and p value estimated by multivariate model accounting for clustering by PCP and adjusting for age, gender, race/ethnicity, e GFR, hypertension, diabetes, and number of PCP visits.