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*
Department of Medicine, University of California, Los Angeles, School of
Medicine, Los Angeles, California
Department of Medicine, University of Minnesota, Minneapolis,
Minnesota
Southwest Center for Managed Care Research, Lovelace Respiratory Research
Institute, Albuquerque, New Mexico
Department of Medicine, New England Medical Center, Boston,
Massachusetts
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Covance Health Economics and Outcomes Services, Inc., Gaithersburg, and
The Johns Hopkins University, Baltimore, Maryland.
Correspondence to Dr. Allen R. Nissenson, UCLA Medical Center, 200 Medical Plaza, Suite 565-59, Los Angeles, CA 90095. Phone: 310-825-9464; Fax: 310-206-2985; E-mail: anissenson{at}mednet.ucla.edu
Abstract. There are between 2 and 13 million Americans with
chronic kidney disease (CKD). Recent reports suggest that their treatment is
currently suboptimal. To further investigate this issue, patterns of practice
for the treatment of patients with CKD who were enrolled in a large health
maintenance organization in New Mexico were analyzed. Among the >200,000
patients who were enrolled in the health maintenance organization between 1994
and 1997, a cohort of 1658 patients who exhibited at least two
gender-specific, elevated creatinine concentrations (Cr), separated by at
least 90 d, were identified. The proportions of patients with Cr values of
<2.0, 2.0 to 2.9, 3.0 to 3.9, and 
4.0 mg/dl were 73, 17, 3, and 7%,
respectively. The majority of patients were treated by a primary care
physician until Cr values reached 3.0 mg/dl, at which time a nephrologist was
consulted. Care tended to be transferred to the nephrologist when the Cr
reached 4.0 mg/dl. Only 7.4% of patients received erythropoietin (EPO). Use of
EPO increased 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 fewer than 20% of patients with CKD with Cr values of 4.0 mg/dl
received an angiotensin-converting enzyme inhibitor (ACEI). Nephrologists were
not more likely to prescribe ACEI than were primary care physicians. Diabetic
patients were more likely to receive ACEI than were nondiabetic patients, but
ACEI use was quite low even among diabetic patients with 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 4.0 mg/dl, compared
with those with Cr values of <2.0 mg/dl. The reasons for hospitalization
were more likely to be related to comorbidities than to CKD itself, however.
There are many opportunities to improve the care of patients with CKD. Better
adherence to practices known 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-makers, and payers should view CKD as a major public health
problem and initiate innovative programs to address this growing patient
population.
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