Quality indicators for the detection and management of chronic kidney disease in primary care in Canada derived from a modified Delphi panel approach

Tu and colleagues present a set of 17 quality indicators for chronic kidney disease (CKD) in primary care. This set includes one indicator on prevalence/incidence, four on diagnosis/screening, and 12 on management/referral of CKD patients. The set was developed in a structured process, including literature research and a consensus method. This is considered the best method for developing quality indicators [1], and gives the indicators face and content validity. Furthermore, they tested the feasibility of applying the indicators to routinely collected data, showing their operational validity for the Canadian primary care setting. It is relevant to establish whether their set could be useful for other countries and settings. In their discussion, Tu and colleagues mention that their set is similar to a US-based set of measures [2] and also overlapping with a Japanese-based set of measures [3]. All three sets include mainly process measures focusing on actions which are within the health care provider's control. In a recent systematic review of process quality indicators for CKD care [4], we identified 273 indicators focusing on aspects of monitoring, prescribing, drug safety, adherence and referral. Ten of these indicators had shown content, face and operational validity in at least one study. Of these ten indicators, five -that were conceptually similar- are in the set of Tu and colleagues. These include: regular monitoring of the glomerular filtration rate (eGFR), albumin-creatinin ratio (ACR), and blood pressure, prescribing of non-steroidal anti-inflammatory drugs (NSAIDs), and referral to a nephrologist for patients with poor kidney function. Other indicators were conceptually different, although sometimes related. For example, where Tu and colleagues developed an indicator on statin prescribing, others have proposed to measure monitoring of lipid levels. We propose that a comprehensive indicator set for CKD in primary care should include monitoring indicators for all relevant risk factors, that is, eGFR, ACR, blood pressure, and lipids [1]. In addition, in our opinion it is important to have a more comprehensive indicator set to evaluate the quality of pharmacological treatment in CKD patients. For this reason, we have developed and tested a set of 16 prescribing quality indicators for patients with CKD in the Netherlands, following a structured approach [5]. Four of the prescribing indicators presented by Tu and colleagues are included in this set, although some with slight variations in definitions. In addition, we developed additional indicators assessing treatment with antihypertensives, phosphate binders, and assessing medication safety [5]. Applying these indicators in primary care, we identified areas for improvement that are similar as observed by Tu and colleagues, related to underprescribing of statins, and underprescribing of ACE-i/ARB in patients with diabetes and albuminuria. In addition, we observed possible overprescribing of metformin in patients with an eGFR<30 ml/min/1.73m2, and overprescribing of combinations of NSAIDs, ACE-i/ARB and diuretics in CKD patients. We hope that quality indicator sets such as these will be implemented in quality assurance programs to identify areas for improvement in CKD care. Finally, for future use in benchmarking programs, it is important that quality indicator sets will be tested on their predictive validity for better clinical outcomes [4].

References 1. Campbell SM, Braspenning J, Hutchinson A, Marshall M. Research methods used in developing and applying quality indicators in primary care. Qual Saf Health Care. 2002;11(4):358-64. 2. Litvin CB, Ornstein SM. Quality indicators for primary care: an example for chronic kidney disease. J Ambul Care Manage. 2014;37(2):171-8. 3. Fukuma S, Shimizu S, Niihata K, Sada KE, Yanagita M, Hatta T, et al. Development of quality indicators for care of chronic kidney disease in the primary care setting using electronic health data: a RAND-modified Delphi method. Clin Exp Nephrol. 2017;21(2):247-56. 4. Smits KP, Sidorenkov G, Bilo HJ, Bouma M, Navis GJ, Denig P. Process quality indicators for chronic kidney disease risk management: a systematic literature review. Int J Clin Pract. 2016;70(10):861-9. 5. Smits KP, Sidorenkov G, Bilo HJ, Bouma M, van Ittersum FJ, Voorham J, et al. Development and initial validation of prescribing quality indicators for patients with chronic kidney disease. Nephrol Dial Transplant. 2016;31(11):1876-86.

Conflict of Interest:

None declared