for their level of kidney dysfunction. Reassuringly, achievement of
guideline-concordant CKD care was greater among individuals
with higher risks of CKD-associated morbidity and mortality than
among those with lower risk.
One important point deserves mention. The practice settings
and patients studied by Allen et al. may not be representative of
those in the US. Minorities represent a larger proportion of the US
population than in this study, and they, as well as the poor, are at
highest risk for ESRD.
Therefore, the relative lack of socio-
demographic patient diversity, leading to a paucity of high-risk
CKD patients, may underestimate the provision of guideline-
concordant CKD care in the US. On the other hand, the affluence
and enhanced multidisciplinary coordination of the health care
system in Massachusetts and the very high percentage of insured
patients likely overestimate the quality of care received by the
average US resident with chronic kidney disease.
Despite these limitations, the study results highlight certain
challenges that impede the adoption of high-quality CKD care
by generalist physicians. Poor provider awareness of CKD and
national CKD management guidelines, and poor communica-
tion among P CPs and nephrologists are two formidable
challenges to overcome. Unsurprisingly, in this study, provider
recognition of CKD was associated with greater monitoring of
kidney disease and decreased prescription of inappropriate
medications; nephrology in volvement was associated with
improved cardiovascular risk reduction and enhanced treat-
ment of metabolic bone disease. Other barriers that impede the
adoption of high-quality CKD care include the prevalence of
higher profile co-morbid chronic illnesses such as diabetes and
cardiovascular disease, national policies that emphasize acute
care visits over ones that focus on care for chronic medical
conditions, and a lack of funding opportunities for CKD
implementation research. Additional challenges shown in
other studies include la ck of e ducation of primary care
physicians in the use of glomerular filtration rate estimating
equations, poor patient-physician communication, and dis-
agreement of generalists and specialists on their respective
roles in CKD management.
It is imperative for future CKD research to focus on the
elimination of these barriers. More effective use of technology to
help providers identify patients with CKD and provision of
enhanced decision support systems to increase the quality of
CKD care in the face of competing comorbid conditions, are
essential to move the field forward. Health care delivery
systems that allow for greater communication between
inte rnists and pharmacists and co-management involving
internists and neph rologists are key to provide targeted,
coordinated, cost-effective care. The creation of sustainable
patient self-management support programs that incorporate
and build upon the patient education tools created by the
National Kidney Dise ase Educa tion Pr ogram and others,
including the National Kidney Foundation, is necessary to
raise general awareness of kidney disease and its complica-
tions and encourage life-style modifications to improve CKD
risk profiles. Finally, a system of national surveillance for CKD,
now underway, is essential to track the nation’s progress in
improving CKD care.
The publication of these two articles underscores the impor-
tance of primary care providers in the care of patients with CKD.
The opportunity to further engage generalists, educators, and
researchers is now. It is time to design and implement interven-
tions that increase recognition of CKD, facilitate delivery of high-
quality, coordinated CKD care, and improve health outcomes for
the growing number of patients affected by the CKD epidemic.
Primary care physicians can rise to this challenge.
Grant Support: Dr. Tuot is supported by an American Kidney Fund
Clinical Scientist. Grant. Dr. Powe is supported by grant K24DK02643
from the National Institute of Diabetes and Digestive and Kidney
Diseases, Bethesda, MD.
Open Access: This article is distributed under the terms of the
Creative Commons Attribution Noncommercial License which per-
mits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
Corresponding Author: Neil R. Powe, MD; Department of Medicine,
San Francisco General Hospital, University of California San
Francisco, 1001 Potrero Ave, 5F38, San Francisco, CA 94110, USA
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