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CKD Prevalence in the Military Health System: Coded Versus Uncoded CKD
Jenna M Norton1, Lindsay Grunwald2, Amanda Banaag2
1Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD.
Insights
Chronic kidney disease (CKD) is often unrecorded in the Military Health System (MHS). Uncoded CKD disproportionately affects younger, female, and active-duty beneficiaries, suggesting potential gaps in care for lower-risk groups.
Area of Science:
- Nephrology
- Public Health
- Health Informatics
Background:
- Chronic kidney disease (CKD) is a prevalent condition that is frequently underdiagnosed or unrecorded in administrative datasets.
- Accurate identification of CKD is crucial for timely intervention and management to prevent disease progression.
Purpose of the Study:
- To determine the prevalence of CKD within the Military Health System (MHS) using both diagnostic codes and an electronic health record-based phenotype.
- To compare the characteristics of beneficiaries with coded versus uncoded CKD to identify potential disparities in diagnosis.
Main Methods:
- A cross-sectional study was conducted using data from MHS beneficiaries aged 18 to 64 years from fiscal years 2016 to 2018.
- CKD was defined using International Classification of Diseases, Tenth Revision (ICD-10) codes and/or a validated electronic phenotype incorporating estimated glomerular filtration rate and proteinuria.
- Statistical analyses, including t-tests and chi-squared tests, were used to compare coded and uncoded CKD populations based on demographic and clinical predictors.
Main Results:
- The MHS population comprised 3,330,893 beneficiaries, with an overall CKD prevalence of 3.2%.
- A significant proportion (63%) of CKD cases were identified through the electronic phenotype without an ICD-10 code (uncoded CKD).
- Beneficiaries with uncoded CKD were younger, more often female and active duty, and less likely to have diabetes or hypertension compared to those with coded CKD.
Conclusions:
- The findings suggest that CKD is under-recorded in the MHS, with a substantial number of cases identified only through electronic phenotyping.
- Individuals with traditionally lower CKD risk factors (e.g., younger age, female sex) were more likely to have uncoded CKD, indicating potential missed diagnoses in these groups.
- The study highlights the importance of utilizing comprehensive phenotyping methods beyond simple diagnostic codes to accurately capture CKD prevalence and ensure equitable care.
Rationale & Objective:
Chronic kidney disease (CKD) is common but often goes unrecorded.
Study Design:
Cross-sectional.
Setting & Participants:
Military Health System (MHS) beneficiaries aged 18 to 64 years who received care during fiscal years 2016 to 2018.
Predictors:
Age, sex, active duty status, race, diabetes, hypertension, and numbers of kidney test results.
Outcomes:
We defined CKD by International Classification of Diseases, Tenth Revision (ICD-10) code and/or a positive result on a validated electronic phenotype that uses estimated glomerular filtration rate and measures of proteinuria with evidence of chronicity. We defined coded CKD by the presence of an ICD-10 code. We defined uncoded CKD by a positive e-phenotype result without an ICD-10 code.
Analytical Approach:
We compared coded and uncoded populations using 2-tailed t tests (continuous variables) and Pearson χ2 test for independence (categorical variables).
Results:
The MHS population included 3,330,893 beneficiaries. Prevalence of CKD was 3.2%, based on ICD code and/or positive e-phenotype result. Of those identified with CKD, 63% were uncoded. Compared with beneficiaries with coded CKD, those with uncoded CKD were younger (aged 45 ± 13 vs 52 ± 11 years), more often women (54.4% vs 37.6%) and active duty (20.2% vs 12.5%), and less often of Black race (18.5% vs 31.5%) or with diabetes (23.5% vs 43.5%) or hypertension (46.6% vs 77.1%; P < 0.001). Beneficiaries with coded (vs uncoded) CKD had greater numbers of kidney test results (P < 0.001).
Limitations:
Use of cross-sectional administrative data prevents inferences about causality. The CKD e-phenotype may fail to capture CKD in individuals without laboratory data and may underestimate CKD.
Conclusions:
The prevalence of CKD in the MHS is ~3.2%. Beneficiaries with well-known CKD risk factors, such as older age, male sex, Black race, diabetes, and hypertension, were more likely to be coded, suggesting that clinicians may be missing CKD in groups traditionally considered lower risk, potentially resulting in suboptimal care.
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