The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) Grant Initiative: Moving Clinical Practice Forward
2010; Elsevier BV; Volume: 55; Issue: 3 Linguagem: Inglês
10.1053/j.ajkd.2009.11.001
ISSN1523-6838
Autores Tópico(s)Health Systems, Economic Evaluations, Quality of Life
ResumoThe National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines have made a substantial impact on the overall care of adults and children with chronic kidney disease (CKD) and have increased awareness of the importance of diagnosing and treating kidney disease for health care providers in all specialties, but especially primary care. Despite ongoing research, many key issues in clinical care remain controversial, with little evidence to support existing management practices. The evidence review process for developing the KDOQI guidelines not only summarizes existing research to create guidelines, but also identifies gaps in knowledge, which then are included as research recommendations.In 2008, the National Kidney Foundation's Board of Directors established the KDOQI Grant Initiative in an effort to expand the evidence base for CKD-related clinical practice. The first Request for Applications (RFA) for the KDOQI Grant Initiative was released September 2008, with the overall goal to stimulate investigation that addresses the research recommendations that accompany each KDOQI guideline and help provide more authoritative guidance regarding appropriate testing and therapies to enhance patient outcomes. The KDOQI Grant Initiative also aimed to fund research that studies the effective use and subsequent impact of implementation of the KDOQI guidelines on patient care and outcomes.The RFA focuses on several fundamental questions for which research can make a substantial impact on clinical care. These vital research questions are identified by the KDOQI Research Initiative Advisory Committee, which reviews research recommendations from all published guidelines and prioritizes them based on feasibility and potential for strengthening and/or expanding the guidelines' evidence base. Applications are then evaluated by the Advisory Committee based on responsiveness to the RFA, the merit of the research project, and the investigator's potential to secure funding to complete the study or take the next steps toward improving patient outcomes. At the time funding begins, the applicant must hold a full-time appointment to a faculty position at a university or an equivalent position on the staff of a nonprofit research organization in the United States. Candidates also must be dues-paying professional members of the National Kidney Foundation Inc.Two KDOQI research grants funded each fiscal year will award each recipient support of $150,000 per year for 3 years. Several excellent applications were received for the first KDOQI Grant Initiative RFA, and the 2 highest scored study proposals were funded. The first 2 KDOQI grant recipients are Dr Chester Fox, a family practice physician/researcher in Buffalo, NY, and Dr Josef Coresh, a physician/epidemiologist from Baltimore, MD (Box 1). Dr Fox's study will examine the process and benefits of implementation of the KDOQI guidelines in primary care practices, while Dr Coresh's research aims to define how newer and updated estimations of kidney function are associated with the complications of kidney disease and how these associations are modified by factors such as the presence of proteinuria or cardiovascular disease. The following summaries highlight their ongoing research efforts funded by the National Kidney Foundation KDOQI Grant Initiative starting July 1, 2009.Box 1KDOQI Grant Initiative Proposals Funded in 2009Title: Implementing KDOQI Guidelines in Primary Care Offices: Translating Evidence Into PracticePrincipal Investigator: Chester H. Fox, MD (Department of Family Medicine, University at Buffalo, Buffalo, NY)Title: Complications and Prognosis of CKD in the US PopulationPrincipal Investigator: Josef Coresh, MD, PhD (Johns Hopkins University School of Public Health, Baltimore, MD)Abbreviations: CKD, chronic kidney disease; KDOQI, Kidney Disease Outcomes Quality Initiative.2009 KDOQI Grant Initiative AwardsImplementing KDOQI Guidelines in Primary Care Offices: Translating Evidence into Practice (Chester H. Fox, MD)BackgroundCKD is steadily increasing in prevalence in the United States.1Hostetter T.H. Lising M. National Kidney Disease Education Program.J Am Soc Nephrol. 2003; 14: S114-S116Crossref PubMed Google Scholar, 2Nickolas T.L. Frisch G.D. Opotowsky A.R. et al.Awareness of kidney disease in the US population: findings from the National Health and Nutrition Examination Survey (NHANES) 1999 to 2000.Am J Kidney Dis. 2004; 44: 185-197Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar The most recent prevalence study, from NHANES (National Health and Nutrition Examination Survey) 1988-1994 and NHANES 1999-2004, has shown that CKD prevalence has increased from 10% to 13%.3Coresh J. Selvin E. Stevens L.A. et al.Prevalence of chronic kidney disease in the United States.[see comment].JAMA. 2007; 298: 2038-2047Crossref PubMed Scopus (3837) Google Scholar Unpublished data from insurance claims show that > 60% of all patients with CKD are treated exclusively in the primary care office. Therefore, primary care physicians (PCPs) are well positioned to detect, monitor, and treat early kidney disease, thereby reducing mortality and improving the quality of life for their patients. However, CKD often is unrecognized in earlier stages by PCPs,4Fox C.H. Brooks A. Zayas L.E. et al.Primary care physicians' knowledge and practice patterns in the treatment of chronic kidney disease: an Upstate New York Practice-based Research Network (UNYNET) study.J Am Board Fam Med. 2006; 19: 54-61Crossref PubMed Scopus (96) Google Scholar and early diagnosis and treatment of CKD and its associated comorbid conditions are vitally important for the prevention and delay of progression to kidney failure and cardiovascular morbidity. To facilitate better detection and treatment of CKD, the National Kidney Foundation developed evidence-based guidelines that are readily available to PCPs (http://www.kidney.org/PROFESSIONALS/kdoqi/guidelines.cfm).Studies have shown that only 10% of PCPs are even aware of the KDOQI guidelines,4Fox C.H. Brooks A. Zayas L.E. et al.Primary care physicians' knowledge and practice patterns in the treatment of chronic kidney disease: an Upstate New York Practice-based Research Network (UNYNET) study.J Am Board Fam Med. 2006; 19: 54-61Crossref PubMed Scopus (96) Google Scholar, 5Boulware L.E. Troll M.U. Jaar B.G. et al.Identification and referral of patients with progressive CKD: a national study.Am J Kidney Dis. 2006; 48: 192-204Abstract Full Text Full Text PDF PubMed Scopus (163) Google Scholar and use of these guidelines is limited. Guideline complexity coupled with time constraints in visits appear to be significant barriers to implementation. Primary care providers have competing time demands,6Jaen C.R. Stange K.C. Nutting P.A. Competing demands of primary care: a model for the delivery of clinical preventive services.J Fam Pract. 1994; 38: 166-171PubMed Google Scholar and a typical office visit of ∼15 minutes does not allow for either preventive screening or chronic disease management to be performed completely.Study GoalsThe goals of this study are to improve CKD care by PCPs within 5 basic areas: (1) recognition of CKD and its complications, (2) appropriate laboratory testing, (3) medication use, (4) earlier referral to nephrologists, and (5) support of Fistula First Breakthrough Initiatives.MethodsThis randomized controlled trial will use a group block allocation scheme and involve 12 primary care practices in the 8-county region of Western New York. A brief educational intervention (control group) will be compared with a multimodality translational intervention that includes academic detailing,7Bertoni A.G. Bonds D.E. Chen H. et al.Impact of a multifaceted intervention on cholesterol management in primary care practices: guideline adherence for heart health randomized trial.Arch Intern Med. 2009; 169: 678-686Crossref PubMed Scopus (42) Google Scholar point-of-care computer decision support,8Emery J. Morris H. Goodchild R. et al.The GRAIDS Trial: a cluster randomised controlled trial of computer decision support for the management of familial cancer risk in primary care.Br J Cancer. 2007; 97: 486-493Crossref PubMed Scopus (80) Google Scholar and practice facilitation through the use of a practice enhancement assistant9Nagykaldi Z. Mold J.W. Robinson A. et al.Practice facilitators and practice-based research networks.J Am Board Fam Med. 2006; 19: 506-510Crossref PubMed Scopus (62) Google Scholar to improve the diagnosis and management of CKD in primary care offices. All patients with CKD as defined by the National Kidney Foundation's KDOQI classification scheme10National Kidney FoundationK/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, classification and stratification.Am J Kidney Dis. 2002; 39: S46-S64Google Scholar will be assessed for outcomes that include CKD diagnosis, use of appropriate and inappropriate medications (eg, renin-angiotensin system blockers, low-dose aspirin, and nonsteroidal anti-inflammatory drugs), previous referral to a nephrologist for estimated glomerular filtration rate (eGFR) < 30 mL/min/1.73 m2, blood pressure control (<130/80 mm Hg), appropriate laboratory testing, and avoidance of intravenous catheters in the nondominant arm. Special cases also will be assessed, including medication contraindications, anemia, vascular access, and vitamin D deficiency. Longitudinal outcome data will be extracted from the electronic medical record at baseline and 12 and 24 months within each study site.For the sites randomly assigned to the intervention group with a practice enhancement assistant, the first step will be to identify adult patients at risk of CKD (family history of CKD or diagnosis of hypertension, diabetes, or cardiovascular disease) who do not have documentation of GFR in their charts. The practice enhancement assistant will estimate a GFR for these patients based on data in their records, then establish a registry of patients with eGFR < 60 mL/min/1.73 m2. This registry will be used to prompt the PCP for CKD diagnosis of undiagnosed patients. The second step will be an ongoing care cycle in which the practice enhancement assistant uses the Quick Reference Guide as a “guideline prompting tool” to aid in the PCP's prevention of CKD progression and management of complications. Practice enhancement assistants will then use the Quick Reference Guide to report guideline recommendations to the PCP based on information extracted from the electronic medical record for patients with CKD. The practice enhancement assistant then presents data and change over time to the physician and office staff for feedback about what does and does not work to make appropriate modifications. The practice enhancement assistant also has the opportunity to share best practices from other practices working on the same project.Clinical SignificanceWith the aging of the population and the obesity epidemic that is resulting in an increased incidence of diabetes, CKD incidence most likely will continue to increase. By enhancing implementation of the KDOQI guidelines in primary care offices, progression of CKD can be delayed and reduce the need for renal replacement therapy and the overall cost of medical care while improving quality of life for patients.Complications and Prognosis of CKD in the US Population (Josef Coresh, MD)BackgroundThe 2002 KDOQI guidelines were guided and enriched by extensive analyses in NHANES and other studies of the cross-sectional associations of a range of complications by level of eGFR. Numerous studies since the publication of these guidelines reenforced the utility of eGFR. However, substantial controversy exists about whether the recommended cutoff value for defining CKD (<60 mL/min/1.73 m2) is the best.11Coresh J. Stevens L.A. Levey A.S. Chronic kidney disease is common: what do we do next?.Nephrol Dial Transplant. 2008; 23: 1122-1125Crossref PubMed Scopus (47) Google Scholar, 12Glassock R.J. Winearls C. An epidemic of chronic kidney disease: fact or fiction?.Nephrol Dial Transplant. 2008; 23: 1117-1121Crossref PubMed Scopus (176) Google Scholar Some focus on eGFR < 45 mL/min/1.73 m2 in older adults13Crowe E. Halpin D. Stevens P. et al.Early identification and management of chronic kidney disease: summary of NICE guidance [abstract].BMJ. 2008; 337: 1530ACrossref PubMed Scopus (139) Google Scholar or age-, sex-, and/or race-specific percentiles,12Glassock R.J. Winearls C. An epidemic of chronic kidney disease: fact or fiction?.Nephrol Dial Transplant. 2008; 23: 1117-1121Crossref PubMed Scopus (176) Google Scholar, 14Poggio E.D. Rule A.D. Can we do better than a single estimated GFR threshold when screening for chronic kidney disease?.Kidney Int. 2007; 72: 534-536Crossref PubMed Scopus (30) Google Scholar whereas others, including ourselves, have called for making the decision based on data related to the prognosis for key outcomes by level of eGFR and key covariates (age, sex, race, albuminuria, diabetes, hypertension, and presence of cardiovascular disease).11Coresh J. Stevens L.A. Levey A.S. Chronic kidney disease is common: what do we do next?.Nephrol Dial Transplant. 2008; 23: 1122-1125Crossref PubMed Scopus (47) Google Scholar, 15Coresh J. Selvin E. Stevens L.A. In reply.Am J Kidney Dis. 2008; 51: 709-710Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Prognosis and staging of CKD was the topic of a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference held in fall 2009, an event endorsed by the KDOQI leadership as the best next step to examine this issue.There is increasing recognition that eGFR should be the beginning, not the end, of an evaluation, and that covariates, including age, sex, race, and albuminuria, are essential to determining prognosis. To answer 2 specific questions, this study will focus on uniform analysis and pooling of data. This study will help determine whether the newly developed CKD Epidemiology Collaboration (CKD-EPI) equation improves on Modification of Diet in Renal Disease (MDRD) Study estimates of GFR in predicting concurrent and future risk. In addition, the influence of key covariates (demographics, albuminuria, diabetes, hypertension, and presence of cardiovascular disease) on the prognostic implications of eGFR levels will be assessed.Study GoalsThis study aims to advance the field by improving on previous data analyses through: (1) use of standardized serum creatinine values, (2) evaluation of the newly developed CKD-EPI 2009 creatinine eGFR equation, (3) expansion of the end points examined to include CKD progression and hospitalizations and acute kidney injury, and (4) meta-analysis of the largest population-based cohort studies using standardized methods.MethodsThis study will use data from NHANES 1988-2006 to compare the cross-sectional relationships of the MDRD Study and CKD-EPI 2009 creatinine eGFR equations with hypertension, anemia, inflammation, and bone/mineral abnormalities. To estimate the risk associated with eGFR and key covariates (age, sex, race, albuminuria, diabetes, hypertension, and presence of cardiovascular disease), analyses will be conducted in 2 large prospective population-based studies (the Atherosclerosis Risk in Communities [ARIC] Study [n = 15,972]) and the NHANES III Linked Mortality Follow-up Study (n = 14,586). Key outcomes will include mortality, cardiovascular disease, CKD progression, and hospitalizations. GFR estimates from the MDRD Study and the CKD-EPI creatinine equations will be compared. Meta-analysis will be conducted for key outcome-covariate combinations using summary data from large population-based studies. The larger sample size is needed for definitive estimates with multiple covariates.The work will be disseminated through peer-reviewed publications, as well as technical reports that allow for more detailed presentation of data for use by researchers and working groups. The work is likely to be modified and evolve in response to suggestions by investigators in the CKD field and investigators contributing data to the meta-analysis exercise. Since the initiation of this grant, the meta-analysis component of the grant has moved faster than anticipated, with excellent response among investigators to a request to contribute results to a standardized data analysis of prognosis in CKD. Standardization of serum creatinine levels in older studies is a difficult area. In addition, data for a wider range of outcomes are still limited. However, for outcomes such as all-cause mortality in general population cohorts, progress may be even more rapid than initially proposed.Clinical SignificanceSuccessful achievement of these aims will provide essential data for KDOQI recommendations regarding the evaluation of individuals for complications of CKD and subsequent risk of related outcomes. The holders of this grant are grateful for the opportunity to pursue this type of collaborative research and the support of the National Kidney Foundation and the scientific community in this undertaking to increase the uniformity, quantity, and quality of data about CKD prognosis. The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines have made a substantial impact on the overall care of adults and children with chronic kidney disease (CKD) and have increased awareness of the importance of diagnosing and treating kidney disease for health care providers in all specialties, but especially primary care. Despite ongoing research, many key issues in clinical care remain controversial, with little evidence to support existing management practices. The evidence review process for developing the KDOQI guidelines not only summarizes existing research to create guidelines, but also identifies gaps in knowledge, which then are included as research recommendations. In 2008, the National Kidney Foundation's Board of Directors established the KDOQI Grant Initiative in an effort to expand the evidence base for CKD-related clinical practice. The first Request for Applications (RFA) for the KDOQI Grant Initiative was released September 2008, with the overall goal to stimulate investigation that addresses the research recommendations that accompany each KDOQI guideline and help provide more authoritative guidance regarding appropriate testing and therapies to enhance patient outcomes. The KDOQI Grant Initiative also aimed to fund research that studies the effective use and subsequent impact of implementation of the KDOQI guidelines on patient care and outcomes. The RFA focuses on several fundamental questions for which research can make a substantial impact on clinical care. These vital research questions are identified by the KDOQI Research Initiative Advisory Committee, which reviews research recommendations from all published guidelines and prioritizes them based on feasibility and potential for strengthening and/or expanding the guidelines' evidence base. Applications are then evaluated by the Advisory Committee based on responsiveness to the RFA, the merit of the research project, and the investigator's potential to secure funding to complete the study or take the next steps toward improving patient outcomes. At the time funding begins, the applicant must hold a full-time appointment to a faculty position at a university or an equivalent position on the staff of a nonprofit research organization in the United States. Candidates also must be dues-paying professional members of the National Kidney Foundation Inc. Two KDOQI research grants funded each fiscal year will award each recipient support of $150,000 per year for 3 years. Several excellent applications were received for the first KDOQI Grant Initiative RFA, and the 2 highest scored study proposals were funded. The first 2 KDOQI grant recipients are Dr Chester Fox, a family practice physician/researcher in Buffalo, NY, and Dr Josef Coresh, a physician/epidemiologist from Baltimore, MD (Box 1). Dr Fox's study will examine the process and benefits of implementation of the KDOQI guidelines in primary care practices, while Dr Coresh's research aims to define how newer and updated estimations of kidney function are associated with the complications of kidney disease and how these associations are modified by factors such as the presence of proteinuria or cardiovascular disease. The following summaries highlight their ongoing research efforts funded by the National Kidney Foundation KDOQI Grant Initiative starting July 1, 2009. Title: Implementing KDOQI Guidelines in Primary Care Offices: Translating Evidence Into PracticePrincipal Investigator: Chester H. Fox, MD (Department of Family Medicine, University at Buffalo, Buffalo, NY)Title: Complications and Prognosis of CKD in the US PopulationPrincipal Investigator: Josef Coresh, MD, PhD (Johns Hopkins University School of Public Health, Baltimore, MD)Abbreviations: CKD, chronic kidney disease; KDOQI, Kidney Disease Outcomes Quality Initiative. Title: Implementing KDOQI Guidelines in Primary Care Offices: Translating Evidence Into Practice Principal Investigator: Chester H. Fox, MD (Department of Family Medicine, University at Buffalo, Buffalo, NY) Title: Complications and Prognosis of CKD in the US Population Principal Investigator: Josef Coresh, MD, PhD (Johns Hopkins University School of Public Health, Baltimore, MD) Abbreviations: CKD, chronic kidney disease; KDOQI, Kidney Disease Outcomes Quality Initiative. 2009 KDOQI Grant Initiative AwardsImplementing KDOQI Guidelines in Primary Care Offices: Translating Evidence into Practice (Chester H. Fox, MD)BackgroundCKD is steadily increasing in prevalence in the United States.1Hostetter T.H. Lising M. National Kidney Disease Education Program.J Am Soc Nephrol. 2003; 14: S114-S116Crossref PubMed Google Scholar, 2Nickolas T.L. Frisch G.D. Opotowsky A.R. et al.Awareness of kidney disease in the US population: findings from the National Health and Nutrition Examination Survey (NHANES) 1999 to 2000.Am J Kidney Dis. 2004; 44: 185-197Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar The most recent prevalence study, from NHANES (National Health and Nutrition Examination Survey) 1988-1994 and NHANES 1999-2004, has shown that CKD prevalence has increased from 10% to 13%.3Coresh J. Selvin E. Stevens L.A. et al.Prevalence of chronic kidney disease in the United States.[see comment].JAMA. 2007; 298: 2038-2047Crossref PubMed Scopus (3837) Google Scholar Unpublished data from insurance claims show that > 60% of all patients with CKD are treated exclusively in the primary care office. Therefore, primary care physicians (PCPs) are well positioned to detect, monitor, and treat early kidney disease, thereby reducing mortality and improving the quality of life for their patients. However, CKD often is unrecognized in earlier stages by PCPs,4Fox C.H. Brooks A. Zayas L.E. et al.Primary care physicians' knowledge and practice patterns in the treatment of chronic kidney disease: an Upstate New York Practice-based Research Network (UNYNET) study.J Am Board Fam Med. 2006; 19: 54-61Crossref PubMed Scopus (96) Google Scholar and early diagnosis and treatment of CKD and its associated comorbid conditions are vitally important for the prevention and delay of progression to kidney failure and cardiovascular morbidity. To facilitate better detection and treatment of CKD, the National Kidney Foundation developed evidence-based guidelines that are readily available to PCPs (http://www.kidney.org/PROFESSIONALS/kdoqi/guidelines.cfm).Studies have shown that only 10% of PCPs are even aware of the KDOQI guidelines,4Fox C.H. Brooks A. Zayas L.E. et al.Primary care physicians' knowledge and practice patterns in the treatment of chronic kidney disease: an Upstate New York Practice-based Research Network (UNYNET) study.J Am Board Fam Med. 2006; 19: 54-61Crossref PubMed Scopus (96) Google Scholar, 5Boulware L.E. Troll M.U. Jaar B.G. et al.Identification and referral of patients with progressive CKD: a national study.Am J Kidney Dis. 2006; 48: 192-204Abstract Full Text Full Text PDF PubMed Scopus (163) Google Scholar and use of these guidelines is limited. Guideline complexity coupled with time constraints in visits appear to be significant barriers to implementation. Primary care providers have competing time demands,6Jaen C.R. Stange K.C. Nutting P.A. Competing demands of primary care: a model for the delivery of clinical preventive services.J Fam Pract. 1994; 38: 166-171PubMed Google Scholar and a typical office visit of ∼15 minutes does not allow for either preventive screening or chronic disease management to be performed completely.Study GoalsThe goals of this study are to improve CKD care by PCPs within 5 basic areas: (1) recognition of CKD and its complications, (2) appropriate laboratory testing, (3) medication use, (4) earlier referral to nephrologists, and (5) support of Fistula First Breakthrough Initiatives.MethodsThis randomized controlled trial will use a group block allocation scheme and involve 12 primary care practices in the 8-county region of Western New York. A brief educational intervention (control group) will be compared with a multimodality translational intervention that includes academic detailing,7Bertoni A.G. Bonds D.E. Chen H. et al.Impact of a multifaceted intervention on cholesterol management in primary care practices: guideline adherence for heart health randomized trial.Arch Intern Med. 2009; 169: 678-686Crossref PubMed Scopus (42) Google Scholar point-of-care computer decision support,8Emery J. Morris H. Goodchild R. et al.The GRAIDS Trial: a cluster randomised controlled trial of computer decision support for the management of familial cancer risk in primary care.Br J Cancer. 2007; 97: 486-493Crossref PubMed Scopus (80) Google Scholar and practice facilitation through the use of a practice enhancement assistant9Nagykaldi Z. Mold J.W. Robinson A. et al.Practice facilitators and practice-based research networks.J Am Board Fam Med. 2006; 19: 506-510Crossref PubMed Scopus (62) Google Scholar to improve the diagnosis and management of CKD in primary care offices. All patients with CKD as defined by the National Kidney Foundation's KDOQI classification scheme10National Kidney FoundationK/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, classification and stratification.Am J Kidney Dis. 2002; 39: S46-S64Google Scholar will be assessed for outcomes that include CKD diagnosis, use of appropriate and inappropriate medications (eg, renin-angiotensin system blockers, low-dose aspirin, and nonsteroidal anti-inflammatory drugs), previous referral to a nephrologist for estimated glomerular filtration rate (eGFR) < 30 mL/min/1.73 m2, blood pressure control (<130/80 mm Hg), appropriate laboratory testing, and avoidance of intravenous catheters in the nondominant arm. Special cases also will be assessed, including medication contraindications, anemia, vascular access, and vitamin D deficiency. Longitudinal outcome data will be extracted from the electronic medical record at baseline and 12 and 24 months within each study site.For the sites randomly assigned to the intervention group with a practice enhancement assistant, the first step will be to identify adult patients at risk of CKD (family history of CKD or diagnosis of hypertension, diabetes, or cardiovascular disease) who do not have documentation of GFR in their charts. The practice enhancement assistant will estimate a GFR for these patients based on data in their records, then establish a registry of patients with eGFR < 60 mL/min/1.73 m2. This registry will be used to prompt the PCP for CKD diagnosis of undiagnosed patients. The second step will be an ongoing care cycle in which the practice enhancement assistant uses the Quick Reference Guide as a “guideline prompting tool” to aid in the PCP's prevention of CKD progression and management of complications. Practice enhancement assistants will then use the Quick Reference Guide to report guideline recommendations to the PCP based on information extracted from the electronic medical record for patients with CKD. The practice enhancement assistant then presents data and change over time to the physician and office staff for feedback about what does and does not work to make appropriate modifications. The practice enhancement assistant also has the opportunity to share best practices from other practices working on the same project.Clinical SignificanceWith the aging of the population and the obesity epidemic that is resulting in an increased incidence of diabetes, CKD incidence most likely will continue to increase. By enhancing implementation of the KDOQI guidelines in primary care offices, progression of CKD can be delayed and reduce the need for renal replacement therapy and the overall cost of medical care while improving quality of life for patients.Complications and Prognosis of CKD in the US Population (Josef Coresh, MD)BackgroundThe 2002 KDOQI guidelines were guided and enriched by extensive analyses in NHANES and other studies of the cross-sectional associations of a range of complications by level of eGFR. Numerous studies since the publication of these guidelines reenforced the utility of eGFR. However, substantial controversy exists about whether the recommended cutoff value for defining CKD (<60 mL/min/1.73 m2) is the best.11Coresh J. Stevens L.A. Levey A.S. Chronic kidney disease is common: what do we do next?.Nephrol Dial Transplant. 2008; 23: 1122-1125Crossref PubMed Scopus (47) Google Scholar, 12Glassock R.J. Winearls C. An epidemic of chronic kidney disease: fact or fiction?.Nephrol Dial Transplant. 2008; 23: 1117-1121Crossref PubMed Scopus (176) Google Scholar Some focus on eGFR < 45 mL/min/1.73 m2 in older adults13Crowe E. Halpin D. Stevens P. et al.Early identificatio
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