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Clinical testing patterns and cost implications of variation in the evaluation of CKD among US physicians
Raquel F Charles1, Neil R Powe, Bernard G Jaar
1Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Insights
Guideline adherence for chronic kidney disease (CKD) diagnosis and management was poor, with many physicians ordering unnecessary tests. This increases patient costs and highlights the need for better guideline implementation.
Area of Science:
- Nephrology
- Healthcare Quality
- Clinical Practice Guidelines
Background:
- Clinical practice guidelines aim to standardize chronic kidney disease (CKD) diagnosis and management.
- However, the extent of adherence, factors influencing it, and associated costs remain underexplored.
Purpose of the Study:
- To evaluate adherence to clinical practice guidelines for CKD diagnosis and management among US physicians.
- To identify determinants of adherence and assess the cost implications of guideline-discordant testing.
Main Methods:
- A cross-sectional survey was distributed to a nationally representative sample of 1,200 US primary care physicians and nephrologists.
- Guideline adherence was defined as recommending at least 5 of 6 key tests for newly identified CKD.
- Additional nonrecommended tests and their associated costs were also evaluated.
Main Results:
- Only 35% of surveyed physicians demonstrated adherence to CKD diagnostic guidelines.
- Nephrologists showed higher adherence than internal medicine and family physicians.
- Physicians with over 10 years of practice had lower adherence rates.
- Eighty-five percent of physicians ordered additional tests, increasing per-patient costs by 23%.
Conclusions:
- Adherence to recommended CKD testing is suboptimal, leading to increased healthcare costs.
- There is a need for enhanced clarity, dissemination, and adoption of existing CKD guidelines.
- Improving guideline uptake can enhance care quality and reduce costs for CKD patients.
Background:
Clinical practice guidelines were established to improve the diagnosis and management of chronic kidney disease (CKD), but the extent, determinants, and cost implications of guideline adherence and variation in adherence have not been evaluated.
Study Design:
Cross-sectional survey.
Settings & Participants:
The questionnaire was sent (on paper or through the internet) to a nationally representative sample of 1,200 US primary care physicians and nephrologists.
Predictor:
Provider and patient characteristics.
Outcomes & Measurements:
Guideline adherence was assessed as present if physicians recommended at least 5 of 6 clinical tests prescribed by the National Kidney Foundation's Kidney Disease Outcomes and Quality Initiative guidelines for a hypothetical patient with newly identified CKD. We also assessed patterns and costs of additional nonrecommended tests for the initial clinical evaluation of CKD.
Results:
Of the 301 (86 family medicine, 89 internal medicine, and 126 nephrology) eligible physicians who responded to the survey (response rate, 32%), most practiced longer than 10 years (54%), were in nonacademic practices (76%), spent greater than 80% of their time performing clinical duties (77%), and correctly estimated kidney function (73%). Overall, 35% of participants were guideline adherent. Compared with nephrologists, internal medicine and family physicians had lower odds of adherence for all recommended testing (odds ratio, 0.6; 95% confidence interval, 0.3 to 1.1; and odds ratio, 0.3; 95% confidence interval, 0.1 to 0.6, respectively). Participants practicing longer than 10 years had lower odds of ordering all recommended testing compared with participants practicing fewer than 10 years (odds ratio, 0.5; 95% confidence interval, 0.3 to 0.9). Eighty-five percent of participants recommended additional tests, which resulted in a 23% increased total per-patient cost of the clinical evaluation.
Limitations:
Recommendations for a hypothetical case scenario may differ from those of actual patients.
Conclusions:
Adherence to recommended clinical testing for the diagnosis and management of CKD was poor, and additional testing was associated with substantially increased cost of the clinical evaluation. Improved clarity, dissemination, and uptake of existing guidelines are needed to improve quality and decrease costs of care for patients with CKD.
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