Medication Prescribing Quality in Australian Primary Care Patients with Chronic Kidney Disease
Abstract
:1. Background
2. Methods
2.1. Statistical Analysis
2.2. Ethics Approval and Consent to Participate
3. Results
3.1. Baseline Charactersitics
3.2. Appropriate Prescribing
3.3. Potentially Inappropriate Prescribing
4. Discussion
5. Strengths and Limitations
Supplementary Materials
Author Contributions
Funding
Acknowledgments
Conflicts of Interest
Consent for Publication
Abbreviations
ACEIs | angiotensin-converting enzyme inhibitors |
ACR | albumin-to-creatinine ratio |
AKI | acute kidney injury |
ARBs | angiotensin receptor blockers |
ATC | anatomical therapeutic chemical |
CKD | chronic kidney disease |
CoC | continuity of care |
EHRs | electronic health records |
eGFR | estimated glomerular filtration rate |
ESAs | erythropoiesis-stimulating agents |
GPs | general practitioners |
KDIGO | Kidney Disease: Improving Global Outcomes |
NSAIDs | non-steroidal anti-inflammatory drugs |
PQIs | prescribing quality indicators |
RAS | renin-angiotensin system |
SEIFA | socio-economic indexes for areas |
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Overall, n = 44,259 n (%) | Diabetes | p Value | ||
---|---|---|---|---|
No n = 30,996 n (%) | Yes n = 13,263 n (%) | |||
Age groups (years) | <0.836 | |||
<65 | 4373 (9.9) | 3069 (9.9) | 1304 (9.8) | |
≥65 | 39,886 (90.1) | 27,927 (90.1) | 11,959 (90.2) | |
Female | 24,165 (54.6) | 17,620 (56.8) | 6545 (49.3) | <0.001 |
Indigenous Status | <0.001 | |||
Indigenous | 436 (1.0) | 212 (0.7) | 224 (1.7) | |
Non-Indigenous | 33,067 (74.7) | 23,020 (74.3) | 10,047 (75.8) | |
Missing | 10,756 (24.3) | 7764 (25.0) | 2992 (22.6) | |
SEIFA quintile * | ||||
≤3 | 12,254 (27.8) | 8302 (26.9) | 3952 (30.0) | <0.001 |
>3 | 31,754 (72.2) | 22,559 (73.1) | 9225 (70.0) | |
Missing | 251 (0.6) | 165 (0.5) | 86 (0.6) | |
Rurality * | <0.001 | |||
Major Cities of Australia | 26,617 (60.4) | 18,468 (59.9) | 8149 (61.8) | |
Regional and Remote Australia | 17,420 (39.6) | 12,385 (40.1) | 5035 (38.2) | |
Missing | 222 (0.5) | 143 (0.5) | 79 (0.6) | |
GP Continuity of Care | <0.001 | |||
Low (<0.75) | 17,421 (39.4) | 11,917 (38.5) | 5504 (41.5) | |
High (≥0.75) | 26,833 (60.6) | 19,075 (61.5) | 7758 (58.5) | |
Missing | 5 (0.0) | 1 (0.0) | 4 (0.0) | |
Documentation of CKD | 11,618 (26.3) | 7722 (24.9) | 3896 (29.4) | <0.001 |
Overall, n = 44,259 n (%) | Diabetes | p Value | ||
---|---|---|---|---|
No n = 30,996 n (%) | Yes n = 13,263 n (%) | |||
CKD Stage | <0.001 | |||
Stage 3a (45–59 mL/min/1.73 m2) | 25,562 (57.8) | 18,724 (60.4) | 6838 (51.6) | |
Stage 3b (30–44 mL/min/1.73 m2) | 13,551 (30.6) | 9093 (29.3) | 4458 (33.6) | |
Stage 4 (15–29 mL/min/1.73 m2) | 4186 (9.5) | 2573 (8.3) | 1613 (12.2) | |
Stage 5 (<15 mL/min/1.73 m2) | 960 (2.2) | 606 (2.0) | 354 (2.7) | |
ACR (mg/mmol) | 0.023 | |||
Normal <2.5 (male) <3.5 (female) | 7877 (17.8) | 3838 (12.4) | 4039 (30.5) | |
Microalbuminuria 2.5–25 (male) 3.5–35 (female) | 4707 (10.6) | 1719 (5.6) | 2978 (22.5) | |
Macroalbuminuria >25 (male) >35 (female) | 2427 (5.5) | 897 (2.9) | 1530 (11.5) | |
Missing | 29,248 (66.1) | 24,532 (79.1) | 4716 (35.6) | |
Indigenous Status | <0.001 | |||
Indigenous | 436 (1.0) | 212 (0.7) | 224 (1.7) | |
Non-Indigenous | 33,067 (74.7) | 23,020 (74.3) | 10,047 (75.8) | |
Missing | 10,756 (24.3) | 7764 (25.0) | 2992 (22.6) | |
Comorbidities | ||||
Hypertension | 35,386 (80.0) | 23,778 (76.7) | 11,608 (87.5) | <0.001 |
Myocardial infarction | 17,945 (40.5) | 11,688 (37.7) | 6257 (47.2) | <0.001 |
Atrial fibrillation | 7038 (15.9) | 4893 (15.8) | 2145 (16.2) | 0.315 |
Anxiety | 5658 (12.8) | 4124 (13.3) | 1534 (11.6) | <0.001 |
Bipolar disorder | 505 (1.1) | 365 (1.2) | 140 (1.1) | 0.290 |
Schizophrenia | 363 (0.8) | 227 (0.7) | 136 (1.0) | 0.002 |
Total n = 44,259 n (%) | Diabetes | p Value | ||
---|---|---|---|---|
No n = 30,996 n (%) | Yes n = 13,263 n (%) | |||
Blood Pressure | ||||
Patients with BP Recorded | 39,716 (89.7) | 27,411 (88.4) | 12,305 (92.8) | <0.001 |
Low Diastolic BP (<70 mmHg) | 13,602 (34.2) | 8935 (32.6) | 4667 (37.9) | <0.001 |
High Systolic BP (>140 mmHg) | 13,338 (33.6) | 9108 (33.2) | 4230 (34.4) | 0.033 |
Pathology | ||||
Patients with phosphate test recorded | 23,133 (52.3) | 16,060 (51.8) | 7073 (53.3) | 0.004 |
Elevated phosphate level (>1.49 mmol/L) | 1322 (5.7) | 872 (5.4) | 450 (6.4) | 0.005 |
Patients with calcium test recorded | 22,818 (51.6) | 16,096 (51.9) | 6722 (50.7) | 0.017 |
Elevated calcium level (>2.54 mmol/L) | 1343 (5.9) | 893 (5.5) | 450 (6.7) | <0.001 |
Low calcium level (<2.10 mmol/L) | 589 (2.6) | 409 (2.5) | 180 (2.7) | 0.584 |
Patients with Hb test recorded | 40,601 (91.7) | 28,723 (92.7) | 11,878 (89.6) | <0.001 |
Low Hb level (<7.5 mmol/L) | 14,125 (34.8) | 9252 (32.2) | 4873 (41.0) | <0.001 |
Medication | ||||
Antihypertensives | ||||
At least one antihypertensives ≠ | 32,782 (74.1) | 21,893 (70.6) | 10,889 (82.1) | <0.001 |
Diuretic | 9539 (21.6) | 5956 (19.2) | 3583 (27.0) | <0.001 |
Beta Blocker | 10,763 (24.3) | 6862 (22.1) | 3901 (29.4) | <0.001 |
Calcium Channel Blocker | 9551 (21.6) | 6232 (20.1) | 3319 (25.0) | <0.001 |
ACEI or ARB | 24,485 (55.3) | 15,978 (51.5) | 8507 (64.1) | <0.001 |
Multiple ACEI or ARB | 1859 (4.2) | 1066 (3.4) | 793 (6.0) | <0.001 |
Statin | 20,411 (46.1) | 12,370 (39.9) | 8041 (60.6) | <0.001 |
All phosphate binders | 244 (0.6) | 155 (0.5) | 89 (0.7) | 0.031 |
Non-calcium-containing phosphate binders | 67 (0.2) | 41 (0.1) | 26 (0.2) | 0.148 |
Calcium-containing phosphate binders | 182 (0.4) | 119 (0.4) | 63 (0.5) | 0.197 |
Vitamin D | 1444 (3.3) | 939 (3.0) | 505 (3.8) | <0.001 |
ESAs | 42 (0.1) | 24 (0.1) | 18 (0.1) | 0.098 |
NSAIDs | 7426 (16.8) | 4862 (15.7) | 2564 (19.3) | <0.001 |
Metformin | 5189 (11.7) | 59 * (0.2) | 5130 (38.7) | <0.001 |
Digoxin | 1516 (3.4) | 976 (3.1) | 540 (4.1) | <0.001 |
Quality Indicator | Numerator | Denominator | Percentage | p Value | ||
---|---|---|---|---|---|---|
Treatment of Hypertension | ||||||
1. Percentage of patients aged 18 to 80 years with CKD stages 4–5 and hypertension who are prescribed antihypertensives unless undesirable because of low diastolic blood pressure | Overall * | 1029 | 1288 | 79.9 | ||
Rurality | Major cities of Australia | 532 | 672 | 79.2 | 0.565 | |
Regional and Remote Australia | 490 | 609 | 80.5 | |||
SEIFA quintile | ≤3 | 345 | 433 | 79.7 | 0.947 | |
>3 | 677 | 848 | 79.8 | |||
CoC | High | 375 | 459 | 81.7 | 0.228 | |
Low | 654 | 829 | 78.9 | |||
CKD documented | No | 380 | 485 | 78.4 | 0.284 | |
Yes | 649 | 803 | 80.8 | |||
Systolic BP | >140 mmHg | 455 | 573 | 79.4 | 0.541 | |
≤140 mmHg | 588 | 728 | 80.8 | |||
Age | <65 years | 318 | 437 | 72.8 | <0.001 | |
≥65 years | 711 | 851 | 83.5 | |||
Sex | Female | 450 | 561 | 80.2 | 0.800 | |
Male | 579 | 727 | 79.6 | |||
2. Percentage of patients aged 18 to 80 years with CKD stages 3–5 and macroalbuminuria treated with multiple antihypertensives who are prescribed a combination of an ACEI or ARB and a diuretic | Overall * | 298 | 1464 | 20.4 | ||
Rurality | Major cities of Australia | 174 | 837 | 20.8 | 0.679 | |
Regional and Remote Australia | 123 | 618 | 19.9 | |||
SEIFA quintile | ≤3 | 94 | 496 | 19.0 | 0.315 | |
>3 | 203 | 958 | 21.2 | |||
CoC | High | 104 | 528 | 19.7 | 0.639 | |
Low | 194 | 936 | 20.7 | |||
CKD documented | No | 148 | 751 | 19.7 | 0.527 | |
Yes | 150 | 713 | 21.0 | |||
Systolic BP | >140 mmHg | 143 | 643 | 22.2 | 0.123 | |
≤140 mmHg | 150 | 792 | 19.0 | |||
Age | <65 years | 74 | 444 | 16.7 | 0.021 | |
≥65 years | 224 | 1020 | 22 | |||
Sex | Female | 102 | 468 | 21.8 | 0.348 | |
Male | 196 | 996 | 19.7 | |||
3. Percentage of patients aged 18 to 80 years with CKD stages 3–5, microalbuminuria and diabetes treated with multiple antihypertensives who are prescribed a combination of an ACEI or ARB and a diuretic | Overall * | 337 | 1634 | 20.6 | ||
Rurality | Major cities of Australia | 190 | 956 | 19.9 | 0.270 | |
Regional and Remote Australia | 147 | 664 | 22.1 | |||
SEIFA quintile | ≤3 | 110 | 513 | 21.4 | 0.672 | |
>3 | 227 | 1106 | 20.5 | |||
CoC | High | 144 | 641 | 22.5 | 0.140 | |
Low | 193 | 993 | 19.4 | |||
CKD documented | No | 216 | 1075 | 20.1 | 0.462 | |
Yes | 121 | 556 | 21.8 | |||
Systolic BP | >140 mmHg | 119 | 563 | 21.1 | 0.667 | |
≤140 mmHg | 213 | 1053 | 20.2 | |||
Age | <65 years | 40 | 228 | 17.5 | 0.215 | |
≥65 years | 297 | 1406 | 21.1 | |||
Sex | Female | 149 | 655 | 22.7 | 0.083 | |
Male | 188 | 979 | 19.2 | |||
Treatment of albuminuria | ||||||
4. Percentage of patients aged 18 to 80 years with CKD stages 3–5 and macroalbuminuria who are prescribed an ACEI or ARB | Overall * | 1084 | 1741 | 62.3 | ||
Rurality | Major cities of Australia | 636 | 1016 | 62.6 | 0.725 | |
Regional and Remote Australia | 441 | 714 | 61.8 | |||
SEIFA quintile | ≤3 | 353 | 573 | 61.6 | 0.705 | |
>3 | 723 | 1156 | 62.5 | |||
CoC | High | 387 | 645 | 60.0 | 0.135 | |
Low | 697 | 1096 | 63.6 | |||
CKD documented | No | 578 | 898 | 64.5 | 0.046 | |
Yes | 506 | 845 | 60.0 | |||
Age | <65 years | 331 | 590 | 56.1 | <0.001 | |
≥65 years | 753 | 1151 | 65.4 | |||
Sex | Female | 327 | 544 | 60.1 | 0.212 | |
Male | 757 | 1197 | 63.2 | |||
5. Percentage of patients aged 18 to 80 years with CKD stages 3–5, microalbuminuria and diabetes who are prescribed an ACEI or ARB | Overall * | 1252 | 1790 | 69.9 | ||
Rurality | Major cities of Australia | 738 | 1064 | 69.4 | 0.516 | |
Regional and Remote Australia | 502 | 709 | 70.8 | |||
SEIFA quintile | ≤3 | 393 | 546 | 72.0 | 0.207 | |
>3 | 846 | 1226 | 69.0 | |||
CoC | High | 502 | 705 | 71.2 | 0.348 | |
Low | 750 | 1085 | 69.1 | |||
CKD documented | No | 841 | 1179 | 71.3 | 0.075 | |
Yes | 411 | 611 | 67.3 | |||
Age | <65 years | 176 | 259 | 68 | 0.450 | |
≥65 years | 1076 | 1531 | 70.3 | |||
Sex | Female | 496 | 711 | 69.8 | 0.891 | |
Male | 759 | 1079 | 70.1 | |||
Prescription of statins | ||||||
6. Percentage of patients aged 50 to 65 years with CKD stages 3–5 who are prescribed a statin | Overall * | 1508 | 3693 | 40.8 | ||
Rurality | Major cities of Australia | 823 | 2023 | 40.7 | 0.898 | |
Regional and Remote Australia | 669 | 1636 | 40.9 | |||
SEIFA quintile | ≤3 | 488 | 1077 | 45.3 | <0.001 | |
>3 | 1004 | 2581 | 38.9 | |||
CoC | High | 542 | 1292 | 42.0 | 0.311 | |
Low | 966 | 2401 | 40.2 | |||
CKD documented | No | 991 | 2547 | 38.9 | <0.001 | |
Yes | 517 | 1146 | 45.1 | |||
Sex | Female | 714 | 1814 | 39.4 | 0.073 | |
Male | 794 | 1879 | 42.3 | |||
Treatment of MBD | ||||||
7. Percentage of patients aged 18 to 80 years with CKD stages 3–5 and with an elevated phosphate level who are prescribed a phosphate binder | 54 | 815 | 6.6 | |||
8. Percentage of patients aged 18 to 80 years with CKD stages 3–5 treated with phosphate binders and with an elevated calcium level who are prescribed a non-calcium-containing phosphate binder | 5 | 7 | 71.4 | |||
9. Percentage of patients aged 18 to 80 years with CKD stages 3–5 treated with phosphate binders and with a low calcium level who are prescribed a calcium-containing phosphate binder | 6 | 12 | 50.0 | |||
Medication safety | ||||||
10. Percentage of patients 18 years or older with CKD stages 3–5 and a prescription of RAS blockers who are prescribed at least two RAS blockers simultaneously | Overall * | 1859 | 24,485 | 7.6 | ||
Rurality | Major cities of Australia | 1175 | 14,639 | 8.0 | 0.002 | |
Regional and Remote Australia | 678 | 9732 | 7.0 | |||
SEIFA quintile | ≤3 | 587 | 7037 | 8.3 | 0.005 | |
>3 | 1264 | 17,317 | 7.3 | |||
CoC | High | 727 | 9756 | 7.5 | 0.499 | |
Low | 1132 | 14,729 | 7.7 | |||
CKD documented | No | 1339 | 18,073 | 7.4 | 0.069 | |
Yes | 520 | 6412 | 8.1 | |||
Age | <65 years | 182 | 2076 | 8.8 | 0.035 | |
≥65 years | 1677 | 22,409 | 7.5 | |||
Sex | Female | 1007 | 13,466 | 7.5 | 0.455 | |
Male | 852 | 11,019 | 7.7 | |||
11. Percentage of patients 18 years or older with CKD stages 3–5 and elevated calcium levels who are prescribed active vitamin D | 67 | 1343 | 5.0 | |||
12. Percentage of patients 18 years or older with CKD stages 3–5 and Hb ≥ 7.5 who are prescribed ESA | 0 | 26,476 | 0.0 | |||
13. Percentage of patients 18 years or older with Egfr < 30 mL/min/1.73 m2 who are prescribed a NSAID | Overall * | 735 | 5146 | 14.3 | ||
Rurality | Major cities of Australia | 421 | 3054 | 13.8 | 0.201 | |
Regional and Remote Australia | 312 | 2072 | 15.1 | |||
SEIFA quintile | ≤3 | 238 | 1496 | 15.9 | 0.033 | |
>3 | 494 | 3627 | 13.6 | |||
CoC | High | 295 | 2058 | 14.3 | 0.935 | |
Low | 440 | 3087 | 14.3 | |||
CKD documented | No | 352 | 2367 | 14.9 | 0.266 | |
Yes | 383 | 2779 | 13.8 | |||
Age | <65 years | 68 | 724 | 9.4 | <0.001 | |
≥65 years | 667 | 4422 | 15.1 | |||
Sex | Female | 360 | 2648 | 13.6 | 0.147 | |
Male | 375 | 2498 | 15.0 | |||
14. Percentage of patients 18 years or older with Egfr < 30 mL/min/1.73 m2 and diabetes who are prescribed metformin | Overall * | 278 | 1967 | 14.1 | ||
Rurality | Major cities of Australia | 149 | 1208 | 12.3 | 0.005 | |
Regional and Remote Australia | 126 | 749 | 16.8 | |||
SEIFA quintile | ≤3 | 80 | 608 | 13.2 | 0.444 | |
>3 | 195 | 1349 | 14.4 | |||
CoC | High | 119 | 829 | 14.4 | 0.810 | |
Low | 159 | 1138 | 14.0 | |||
CKD documented | No | 136 | 835 | 16.3 | 0.019 | |
Yes | 142 | 1132 | 12.5 | |||
Age | <65 years | 32 | 244 | 13.1 | 0.625 | |
≥65 years | 246 | 1723 | 14.3 | |||
Sex | Female | 127 | 957 | 13.3 | 0.285 | |
Male | 151 | 1010 | 15 | |||
15. Percentage of patients 18 years or older with eGFR < 50 mL/min/1.73 m2 who are prescribed digoxin > 0.125 mg/day | Overall * | 995 | 26,434 | 3.8 | ||
Rurality | Major cities of Australia | 558 | 16,020 | 3.5 | 0.002 | |
Regional and Remote Australia | 433 | 10,282 | 4.2 | |||
SEIFA quintile | ≤3 | 293 | 7394 | 4.0 | 0.295 | |
>3 | 697 | 18,893 | 3.7 | |||
CoC | High | 366 | 10,623 | 3.4 | 0.025 | |
Low | 629 | 15,807 | 4.0 | |||
CKD documented | No | 696 | 17,547 | 4.0 | 0.015 | |
Yes | 299 | 8887 | 3.4 | |||
Age | <65 years | 25 | 2252 | 1.1 | <0.001 | |
≥65 years | 970 | 24,182 | 4.0 | |||
Sex | Female | 596 | 14,411 | 4.1 | <0.001 | |
Male | 399 | 12,023 | 3.3 | |||
16. Percentage of patients 18 years or older with CKD stages 3–5 and who are prescribed with a combination of NSAID, RAS blocker and diuretic | Overall * | 1160 | 44,259 | 2.6 | ||
Rurality | Major cities of Australia | 663 | 26,617 | 2.5 | 0.032 | |
Regional and Remote Australia | 492 | 17,420 | 2.8 | |||
SEIFA quintile | ≤3 | 397 | 12,254 | 3.2 | <0.001 | |
>3 | 757 | 31,758 | 2.4 | |||
CoC | High | 452 | 17,421 | 2.6 | 0.777 | |
Low | 708 | 26,833 | 2.6 | |||
CKD documented | No | 809 | 32,641 | 2.5 | 0.002 | |
Yes | 351 | 11,618 | 3.0 | |||
Age | <65 years | 86 | 4373 | 2.0 | 0.004 | |
≥65 years | 1074 | 39,886 | 2.7 | |||
Sex | Female | 640 | 24,165 | 2.6 | 0.691 | |
Male | 520 | 20,094 | 2.6 |
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Bezabhe, W.M.; Kitsos, A.; Saunder, T.; Peterson, G.M.; Bereznicki, L.R.; Wimmer, B.C.; Jose, M.; Radford, J. Medication Prescribing Quality in Australian Primary Care Patients with Chronic Kidney Disease. J. Clin. Med. 2020, 9, 783. https://doi.org/10.3390/jcm9030783
Bezabhe WM, Kitsos A, Saunder T, Peterson GM, Bereznicki LR, Wimmer BC, Jose M, Radford J. Medication Prescribing Quality in Australian Primary Care Patients with Chronic Kidney Disease. Journal of Clinical Medicine. 2020; 9(3):783. https://doi.org/10.3390/jcm9030783
Chicago/Turabian StyleBezabhe, Woldesellassie M., Alex Kitsos, Timothy Saunder, Gregory M. Peterson, Luke R. Bereznicki, Barbara C. Wimmer, Matthew Jose, and Jan Radford. 2020. "Medication Prescribing Quality in Australian Primary Care Patients with Chronic Kidney Disease" Journal of Clinical Medicine 9, no. 3: 783. https://doi.org/10.3390/jcm9030783