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

描述（由申请人提供）：一些报告揭示了慢性肾脏疾病（CKD）的高患病率，不被重视和经常缺乏护理。为了改善这一人群的健康状况并将终末期肾脏疾病（ESRD）的发生率降至最低，实践指南，包括最著名的肾脏疾病结局质量倡议（K/DOQI），已经发布并得到肾脏界的认可。在这些备受推崇的指南发布之前、期间和之后，通过跟踪临床表现指标（CPM）来监测这些指南的影响是很重要的。然而，由于向慢性肾病患者提供服务的卫生保健系统的结构和边界定义不清，因此在慢性肾病中这样做是困难的。VHA是美国最大的医疗保健网络，拥有明确的组织，可识别的提供者骨干，以及非常适合检查CKD护理实践指南影响的综合数据库。研究目标：我们将评估包括K/DOQI在内的关键实践指南对CKD患者的识别和护理的影响，通过对CPM的连续检查，涵盖这些指南发布的时间。研究设计：我们将对CKD患者的年度样本进行横断面分析，以检查CKD特异性CPM的趋势。研究对象：VHA的受益人将被纳入2000年至2005年的一系列年度队列之一，如果他们在纳入年度期间有肾小球滤过率（GFR）估计为60 ml/min的肾功能下降的实验室证据。还将探讨CKD的其他定义。研究测量：受试者将从肾功能指标测量开始监测12个月的离散性CPM的发生情况。这些绩效指标包括若干经K/DOQI认可的指标，以及由于可能存在特定疾病的医疗风险或对患者安全的威胁而应避免的其他新措施。CPM将被视为二项变量，在序列样本中表示为比例，并分析在提议的研究年份的趋势。预期结果：在大型医疗机构（如VHA）中传播实践指南将显著改善对CKD患者的认识和护理，在指定的研究期间，建议的CPM有显著的有利趋势。这是一项对VHA管理和临床数据的二次分析，这些数据是多年来确定患有慢性肾脏疾病的退伍军人的，以评估实践指南对其疾病特异性护理质量的影响。

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.