Quality indicators for primary health care in chronic kidney disease in the public service of a city in the State of São Paulo, Brazil

Samaan, Farid; Fernandes, Danilo Euclides; Kirsztajn, Gianna Mastroianni; Sesso, Ricardo de Castro Cintra; Malik, Ana Maria

doi:10.1590/0102-311X00090821

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ARTICLE • Cad. Saúde Pública 38 (2) • 2022 • https://doi.org/10.1590/0102-311X00090821 copy

Quality indicators for primary health care in chronic kidney disease in the public service of a city in the State of São Paulo, Brazil

Qualidade de atenção primária em doença renal crônica em um serviço público de um município do Estado de São Paulo, Brasil

Calidad de los cuidados de salud en la atención primaria relacionados con la enfermedad crónica de riñón en un servicio público en una ciudad del Estado de São Paulo, Brasil

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract:

Complications of chronic kidney disease (CKD) can be avoided when promptly diagnosed and treated. The objective was to describe quality indicators of CKD detection and health care in the primary care public service of a city in the State of São Paulo, Brazil. This retrospective study analyzed charts of patients who attended primary care in the public service between November 2019 and February 2020. We selected 10 health quality indicators based on their scientific relevance and availability from the medical records that could express how CKD was identified and managed in primary health care. We estimated the adequate percentage of health indicators with data from 1,066 individuals who had ≥ one risk factor for CKD: hypertension, diabetes, or > 60 years old. Among patients, 79.4% had information on serum creatinine, whereas 58.8% were investigated for proteinuria. Blood pressure data were found in 98.9% of the records. The percentage of patients with blood pressure < 140x90mmHg, glycosylated hemoglobin < 6.5% and LDL-cholesterol < 100mg/dL was 79.2%, 49.2%, and 33.3%, respectively. Renin-angiotensin system blockers were prescribed to 82.8% of the patients with hypertension and CKD. Serum potassium was measured in 35.7% for those who were using renin-angiotensin system blockers. Among those people with CKD, 16.7% had CKD assigned in the medical records as a diagnose. Among those participants at higher risk for CKD, the referral rate to a nephrologist was 31.6%. This study confirmed some missed quality indicators of CKD in primary healthcare. Our results may help administrators develop public policies that improve health care for individuals at high risk for CKD. Long-term follow-up of the health indicators we proposed here will be useful to assess the impact of policy intervention.

Keywords:
Chronic Renal Insufficiency; Health Status Indicators; Primary Health Care

Demographic characteristic	n (%)
Age (years) [mean (SD)]	61.2 (51.8-67.8)
Male sex	421 (39.5)
White	434 (40.7)
Risk factors for CKD
Hypertension	824 (77.3)
Diabetes	464 (43.5)
Hypertension, non-diabetic	483 (45.3)
Diabetes, non-hypertensive	123 (11.5)
Older adults, non-hypertensive, non-diabetic	115 (10.8)
Comorbidities
Dyslipidemia	489 (45.9)
CKD	137 (12.9)
Heart failure	26 (2.4)
Coronary insufficiency	24 (2.3)
Stroke	17 (1.6)
Clinical data
Systolic blood pressure (mmHg) [mean (SD)]	127 (117-137)
Diastolic blood pressure (mmHg) [mean (SD)]	73 (80-85)
Serum creatinine (mg/dL) [mean (SD)]	0.76 (0.84-1.00)
eGFR (mL/min/1.73m²) [mean (SD)]	69.9 (82.2-3.5)
Glycosylated hemoglobin (%) [mean (SD)]	5.6 (6.0-6.7)
LDL-cholesterol (mg/dL) [mean (SD)]	93 (116-141)
Follow-up (years) [mean (SD)]	3 (2.6-3.6)

Indicator	Numerator	Denominator	%
Patients with blood pressure recorded in the previous 12 months	1,054	1,066	98.9
Patients with serum creatinine recorded in the previous 12 months
Total	846	1,066	79.4
Hypertensive, non-diabetic	367	483	76.0
Diabetic, non-hypertensive	104	123	84.6
Older adults, non-hypertensive, non-diabetic	93	115	80.9
Patients with a test for proteinuria recorded in the previous 12 months
Total	627	1,066	58.8
Hypertensive, non-diabetic	277	483	57.4
Diabetic, non-hypertensive	77	123	62.6
Older adults, non-hypertensive, non-diabetic	72	115	62.6
Hypertensive patients with blood pressure < 140x90mmHg	647	817	79.2
Diabetic patients with HbA1c < 6.5%	186	378	49.2
Dyslipidemia patients with LDL-cholesterol < 100mg/dL	138	415	33.3
Patients with CKD that were identified	23	137	16.8
Patients who were referred to a nephrologist	6	19	31.6
Patients with CKD and hypertension who were taking renin-angiotensin system blockers, unless contraindicated	96	116	82.8
Patients who were taking renin-angiotensin system blockers who had their serum potassium measured within the last 12 months	248	694	35.7

CKD stages	eGFR (mL/min)	Proteinuria
CKD stages	eGFR (mL/min)	Absent/Mild	Moderate	Severe
1	≥ 90	194 (31.8) **	9 (1.5) ***	3 (0.5) ^#
2	60-89	319 (52.2) **	11 (1.8) ***	3 (0.5) ^#
3a	45-59	45 (7.4) ***	5 (0.8) ^#	3 (0.5) ^##
3b	30-44	11 (1.8) ^#	2 (0.3) ^##	1 (0.2) ^##
4	15-29	3 (0.5) ^##	2 (0.3) ^##	0 (0) ^##
5	< 15	0 (0) ^##	0 (0) ^##	0 (0) ^##

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[1] Correspondence
D. E. Fernandes Universidade Federal de São Paulo. Rua Botucatu 591, São Paulo, SP 04023-900, Brasil. defernandes@unifesp.br