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

描述（由申请人提供）：几份报告显示慢性肾脏疾病（CKD）患者的患病率高、认识不足和经常护理不良。为了改善这一人群的健康状况并最大限度地减少终末期肾病（ESRD）的发生率，已发布实践指南，其中最值得注意的是肾脏疾病结局质量倡议（K/DOQI），并得到肾脏界的认可。重要的是要通过跟踪临床性能指标（CPM）之前，期间和之后发布的高度重视的指南，这样的指南的影响进行监测。然而，在CKD中这样做是困难的，因为向患有这种疾病的人群提供服务的卫生保健系统的结构和边界定义不清。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和全面的数据库，非常适合检查实践指南对CKD护理的影响。研究目的：我们将评估关键实践指南（包括K/DOQI）对CKD患者的识别和护理的影响，方法是在涵盖这些指南发布时间的一个时期内连续检查CPM。研究设计：我们将对CKD患者的年度样本进行横断面分析，检查CKD特异性CPM的趋势。研究对象：如果VHA的受益者在入选当年有肾功能降低（定义为估计肾小球滤过率（GFR）≥ 60 ml/min）的实验室证据，则将其纳入2000年至2005年期间的一系列年度队列之一。还将探索CKD的替代定义。研究指标：将从肾功能指标开始监测受试者12个月，以确定是否发生离散CPM。这些性能指标包括K/DOQI认可的几个指标，以及由于潜在的疾病特异性医疗风险或对患者安全的威胁而应避免的其他新的实践措施。CPM将被视为二项式变量，表示为系列样本中的比例，并分析拟定研究年的趋势。预期结果：在VHA等大型医疗保健组织中传播实践指南将显著改善CKD患者的识别和护理，在指定的研究间隔内，拟定的CPM具有显著的有利趋势。这是一项对VHA管理和临床数据的二次分析，这些数据是关于几年来被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.