Facility-level variations in diabetic kidney disease care within the VA health system

A new study has uncovered variation across facilities in the Veterans Affairs (VA) Health System concerning the delivery of key measures of kidney disease care for veterans with diabetes. The findings, which appear in an upcoming issue of the Clinical Journal of the American Society of Nephrology (CJASN), point to areas where care might be improved and standardized among facilities.

The VA Health System is the largest integrated health care system in the United States, and several programs have been implemented to improve the quality of care delivered through the health system to patients with chronic kidney disease (CKD). To assess the extent to which care for patients with CKD varies across different VA facilities, Sankar Navaneethan, MD, MS, MPH (Baylor College of Medicine) and his colleagues examined information on 281,233 patients with diabetes and concomitant CKD receiving care in 130 facilities across the VA Health Care System in 2013-2014.

Among those with stage 3 CKD, the median proportions of patients receiving guideline-recommended core measures were 37% for urine albumin:creatinine ratio/urine protein:creatinine ratio, 74% for hemoglobin measurement, 66% for angiotensin converting enzyme inhibitor/angiotensin receptor blocker prescriptions, 85% for statin prescriptions, 47% for achieving blood pressure <140/90 mm Hg, and 13% for meeting all outcome measures. The investigators also found considerable variation across facilities.

"Despite the ongoing best efforts to improve the care for veterans with diabetes and kidney disease, adherence to guideline-recommended core measures such as ordering of certain laboratory tests, and scheduling of referrals to kidney specialists in eligible patients remains suboptimal, with modest facility-level variations for some measures and larger facility-level variation for others. It is important to note that these rates are similar, if not better than other health care systems," said Dr. Navaneethan. "Our results point out potential areas where additional efforts and programs could be implemented to address practice level variations noted among VA facilities."

In an accompanying editorial, Tyler Woodell, MD and Dena Rifkin, MD, MS (University of California, San Diego) note that certain measures are likely practiced with appropriate adherence and variability that reflect patient-centered care, but other measures must improve. "Clinical leaders should review this information, identify potential deficiencies, and defend those situations in which seemingly inappropriate care is actually appropriate," they wrote. "We can then propose solutions such as automated opt-out order sets, clinical reminders, or patient- centered integration of competing demands to improve care delivery in pursuit of the 'right rate.'"