Effect of practice guidelines on care of chronic kidney disease in the VHA

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DESCRIPTION (provided by applicant): Several reports have revealed a high prevalence, under-recognition and frequent poor care of persons with chronic kidney disease (CKD). In an effort to improve the well being of this population and minimize the incidence of end-stage renal disease (ESRD), practice guidelines, including most notably the Kidney Disease Outcome Quality Initiative (K/DOQI), have been released and endorsed by the renal community. It is important to monitor the impact of such guidelines by tracking clinical performance measures (CPM's) before, during and after the release of such highly regarded guidelines. However, efforts to do so are difficult in CKD because of the poorly defined structure and boundaries of the health care systems providing services to the population with this illness. The VHA is the largest health care network in this country with a well-defined organization, identifiable cadre of providers, and a comprehensive data base well suited for the examination of the impact of practice guidelines on CKD care. Study objectives: We will assess the impact of key practice guidelines including K/DOQI on the recognition and care of persons with CKD through examination of CPM's serially over an era that encompasses the time of issuance of these guidelines. Study design: We will conduct cross-sectional analyses of annual samples of persons with CKD examining trends in CKD-specific CPM's. Study subjects: Beneficiaries from the VHA will be included in one of a series of annual cohorts, dating from 2000 to 2005, if they have laboratory evidence for reduced renal function defined by an estimated glomerular filtration rate (GFR) of = 60 ml/min, during the year of inclusion. Alternative definitions of CKD will also be explored. Study measures: Subjects will be monitored for 12 months from the index measure of renal function for the occurrence of discrete CPM's. These performance indicators include several that are endorsed by K/DOQI and additional novel measures of practices to be avoided because of the potential for disease-specific medical risk, or threats to patient safety. The CPM's will be treated as binomial variables, expressed as proportions in the serial samples, and analyzed for trends over the proposed study years. Expected findings: Dissemination of practice guidelines in a large health care organization such as the VHA will lead to significant improvements in the recognition and care of persons with CKD, with significant favorable trends in the proposed CPM's over the designated study interval. This is a secondary analysis of VHA administrative and clinical data on veterans identified with chronic kidney disease over several years to assess the effect of practice guidelines on the quality of their disease-specific care.