Monitoring and management of chronic kidney disease in ambulatory care - analysis of clinical and claims data from a population-based study.

BACKGROUND: Although chronic kidney disease (CKD) is highly prevalent in the general population, little research has been conducted on CKD management in ambulatory care. Objective was to assess management and quality of care by evaluating CKD coding in ambulatory care, patient diagnosis awareness, frequency of monitoring and whether appropriate patients are referred to nephrology. METHODS: Clinical data from the population-based cohort Study of Health in Pomerania (SHIP-START) were matched with claims data of the Association of Statutory Health Insurance Physicians. Quality of care was evaluated according international and German recommendations. RESULTS: Data from 1778 participants (56% female, mean age 59 years) were analysed. 10% had eGFR < 60 ml/min/1.73m2 (mean age 74 years), 15% had albuminuria. 21% had CKD as defined by KDIGO. 20% of these were coded and 7% self-reported having CKD. Coding increased with GFR stage (G3a 20%, G3b 61%, G4 75%, G5 100%). Serum creatinine and urinary dip stick testing were billed in the majority of all participants regardless of renal function. Testing frequency partially surpassed recommendations. Nephrology consultation was billed in few cases with stage G3b-G4. CONCLUSION: CKD coding increased with stage and was performed reliably in stages ≥ G4, while CKD awareness was low. Adherence to monitoring and referral criteria varied, depending on the applicability of monitoring criteria. For assessing quality of care, consent on monitoring, patient education, referral criteria and coordination of care needs to be established, accounting for patient related factors, including age and comorbidity. TRIAL REGISTRATION: This study was prospectively registered as DRKS00009812 in the German Clinical Trials Register (DRKS).

[Perspective of General Practitioners on Management of Non-dialysis Chronic Kidney Disease - a Qualitative Study]. / Management der nicht dialysepflichtigen chronischen Niereninsuffizienz aus hausärztlicher Sicht ­ eine qualitative Studie.

BACKGROUND: Chronic Kidney Disease (CKD) is a common diagnosis in older age due to age dependent kidney function decline, as well as an increase in causative diseases like diabetes mellitus and arterial hypertension. The condition knows a long asymptomatic phase in the early stages, and only a small part of the patient will progress to end stage renal disease requiring renal replacement therapy. Patients with CKD are generally managed by General Practitioners (GPs). OBJECTIVES: The aim of the study was to evaluate the perspectives of German GPs on management of patients with non-dialysis CKD. METHODS: There were 5 focus group discussions with a maximum of 5 GPs (n = 22). The material was recorded and transcribed to be analyzed by content analysis. RESULTS: The most important treatment measures at the CKD were the optimization of causative diseases, medication adjustment and referral for nephrologist consultation. GPs stressed the individual management of their CKD patients. CONCLUSION: GPs reported that their decisions about CKD management were based on Individual patient factors such as high age or multimorbidity.

Fairness and objectivity of a multiple scenario objective structured clinical examination.

Introduction: The aim of the Objective Structured Clinical Examination (OSCE) is a standardized and fair assessment of clinical skills. Observing second clinical year medical students during a summative OSCE assessing a General Practice clerkship, we noticed that information exchange with peers led to a progressively faster and overly focused management of simulations. Therefore, we established a Multiple Scenario-OSCE (MS-OSCE) where all students had to manage the same chief complaint at a station but it's underlying scenarios being randomly changed during students' rotation through their parcours. We wanted to ensure they fully explore differential diagnosis instead of managing their task influenced by shared information. We wanted to assess if a MS-OSCE violates the assumption of objectivity and fairness given that students are not tested with the same scenarios. Methods: We developed and piloted five OSCE stations (chest pain, abdominal pain, back pain, fatigue and acute cough) with two or three different underlying scenarios each. At each station these scenarios randomly changed from student to student. Performance was assessed with a checklist and global rating. The effect of scenarios and raters on students' grades was assessed calculating the intraclass correlation coefficient with a fixed effect two level linear model. Results: A total of 169 students and 23 raters participated in the MS-OSCE. The internal consistency over all stations was 0.65 by Cronbach's alpha. The difference of the mean grades between the scenarios of a given chief complaint ranged from 0.03 to 0.4 on a 1 to 5 grading scale. The effect of scenarios on the variance of the final grades at each station ranged from 4% to 9% and of raters from 20% to 50% when adjusted for students' skills. Conclusions: The effect of different scenarios on the grades was relevant but small compared to the effect of raters on grades. Improving rater training is more important to ensure objectivity and fairness of MS-OSCE than providing the same scenario to all students.

Nephrologists' perspectives on ambulatory care of patients with non-dialysis chronic kidney disease - A qualitative study.

Little is known on the perspectives of nephrologists on managing non-dialysis patients with chronic kidney disease (CKD). The purpose of this qualitative study was to explore the experiences and perspectives of nephrologists regarding the interface with general practitioners (GP) and GPs' management of patients with non-dialysis CKD, so that barriers to cooperation and need for improved management can be identified. Twenty semi-structured interviews were conducted for this qualitative study. The interviews were audio-recorded and coded to be analysed. The concept of knowledge systems served as a sensitising concept. Optimising underlying diseases, medication adaptation and patient awareness of CKD were regarded as the most important treatment measures in CKD management. Differing views exist on who should be responsible for lifestyle interventions, patient education and timing of referral. Nephrologists generally preferred the referral of patients with high progression risk and co-treatment models in which daily care was performed by GP, but some preferred referral of all patients with early CKD and some nephrologists stated that patient care should be in the hands of nephrologists entirely in case of CKD. Doctor-patient communication predominantly remained within the medical-scientific knowledge system whereas patients' everyday knowledge systems were rarely considered. While stressing optimisation of laboratory values, diabetes and hypertension, patients' perspectives and shared decision-making to identify and prioritise patients' individual health goals were rarely considered by nephrologists. Instead, most nephrologists regarded educating patients and GPs as an important part of their professional role. Defining the interface between GPs and nephrologists, with specific recommendations on when to refer and which tasks each professional group should perform can lead to standardisation and improved interdisciplinary management of CKD patients. Addressing patients' everyday knowledge systems can be valuable in formulating and prioritising health goals with patients.

Diagnosis and management of non-dialysis chronic kidney disease in ambulatory care: a systematic review of clinical practice guidelines.

BACKGROUND: Chronic kidney disease (CKD) is age-dependent and has a high prevalence in the general population. Most patients are managed in ambulatory care. This systematic review provides an updated overview of quality and content of international clinical practice guidelines for diagnosis and management of non-dialysis CKD relevant to patients in ambulatory care. METHODS: We identified guidelines published from 2012-to March 2018 in guideline portals, databases and by manual search. Methodological quality was assessed with the Appraisal of Guidelines for Research and Evaluation II instrument. Recommendations were extracted and evaluated. RESULTS: Eight hundred fifty-two publications were identified, 9 of which were eligible guidelines. Methodological quality ranged from 34 to 77%, with domains "scope and purpose" and "clarity of presentation" attaining highest and "applicability" lowest scores. Guidelines were similar in recommendations on CKD definition, screening of patients with diabetes and hypertension, blood pressure targets and referral of patients with progressive or stage G4 CKD. Definition of high risk groups and recommended tests in newly diagnosed CKD varied. CONCLUSIONS: Guidelines quality ranged from moderate to high. Guidelines generally agreed on management of patients with high risk or advanced CKD, but varied in regarding the range of recommended measurements, the need for referrals to nephrology, monitoring intervals and comprehensiveness. More research is needed on efficient management of patients with low risk of CKD progression to end stage renal disease.

[Patients Ability to Provide Information about Prescribed Drugs - a Cross-Sectional Study in Ten General Practice]. / Auskunftsfähigkeit von Patienten über ihre ärztlich verordneten Medikamente ­ Eine Querschnittstudie in zehn Allgemeinarztpraxen.

BACKGROUND: For the correct intake and safe handling of their own medication it is important that patients know about their own medication and can give certain information. This study examines what information patients can provide about their prescribed medication and which factors influence the ability to provide information. METHODS: A cross-sectional study was conducted. In 10 General Practice, 637 patients (participation rate 57 %) were asked about the name, dosage, frequency of intake and indication of their prescribed medication. The patient information were compared with the practice documentation. RESULTS: Patient data on the number of medications were 54 % consistent with the practice documentation. There is a relevant discrepancy between the documented drug prescription and the information provided by patients. The patients were best able to provide information about the names (75 %) of their medications and worst about the indication (47 %). The ability to provide information decreased in patients with ≥ 5 medications. An association between higher education and correct information was found. 65 % of the participants had a medication plan and 19 % used the plan to answer the questions. The possession of a medication plan showed no effect. However the use of a medication plan had an effect, which was even stronger in patients with ≥ 5 medications. CONCLUSION: Most patients did not use the medication plan, which is why the issue of a medication plan does not lead to better information. Technical solutions, such as centralized data storage, should be developed, which can guarantee the security of supply and drug therapy and the exchange between different physicians and institutions, regardless of an incomplete and often non-existent paper or electronic health card medication plan.

[Local Allergic Reaction to Subcutaneous Treatment with Procaine in a Patient with Shoulder Pain - a Case Study]. / Lokale allergische Reaktion nach subkutaner Applikation von Procain bei einem Patienten mit Schulterschmerzen ­ Fallbericht.

HISTORY: A 53-year-old man presented at the general practitioner's office with 2 weeks of existing shoulder pain without radiation. On physical examination, no abnormalities were found, except for left-sided tension of the shoulder muscles. FINDINGS AND DIAGNOSIS: Because of the expected self-limiting nature of the complaints, no further tests were conducted. Based on shoulder pain with local muscle tension, the working diagnosis cervicobrachialgia was adopted. THERAPY AND COURSE: The pain was treated with local subcutaneous administration of procaine. 4 days later, the patient presented with distinct patches of urticaria at the injection sites, which regressed spontaneously over the course of 2 weeks. DISCUSSION: Allergic reactions occuring after treatment with procaine are rare, but can be life-threatening if systemic or afflicting vital structures.Patients should be informed about the importance of the allergy in relation to medical procedures, such as dental treatment, and about cross-reactivity with other medication.

[Cancer screening in the elderly: Explorative mixed methods study]. / Krebsfrüherkennungsuntersuchungen im hohen Alter: Explorative "Mixed-methods"-Studie.

BACKGROUND: The benefits of cancer screening in the elderly are uncertain. While the risk of cancer increases with age the participation in cancer screening decreases. AIM: The study investigated the attitudes of older adults towards cancer screening as well as their motives for or against participation. MATERIAL AND METHODS: This population-based explorative mixed methods study was based on a survey of residents aged 69-89 years from the district of Western Pomerania-Greifswald (northeast Germany). Criteria for exclusion were cognitive deficits and/or cancer. Attitudes towards different statements regarding cancer screening were assessed by a questionnaire using 5-point Likert scales. Semi-structured interviews were used to explore the motivations. RESULTS: Out of 630 contacted residents, 120 (19%) with an average age of 77 years (SD ± 6 years) participated in the face-to-face survey. The majority were in favor of lifelong cancer screening, 14% stated other health problems to be more important than cancer screening and 7% assumed that they would not live long enough to benefit from screening. Motives for participation in cancer screening were habit, regularity, sense of obligation, fear and belief in benefits. Motives for discontinuing screening included a lack of interest, no assumed necessity and fear. Disadvantages were not feared. CONCLUSION: Elderly people show great trust in cancer screening. They overestimated the benefits of cancer screening and their risk to die of cancer. The elderly should be better informed about the benefits and risks of cancer screening. Shared decision-making should be based on life expectancy and personal preferences.