Quality of Care in Chronic Kidney Disease and Incidence of End-stage Renal Disease in Older Patients: A Cohort Study

Med Care. 2020 Jul;58(7):625-631. doi: 10.1097/MLR.0000000000001301.


Background: The quality of care received by a growing number of older patients with chronic kidney disease (CKD) has not been adequately examined.

Objective: The objective of this study was to assess the quality of CKD care among older patients and to clarify its association with the incidence of end-stage renal disease (ESRD).

Research design: This was a population-based cohort study.

Subjects: Older (65 y and above) CKD patients diagnosed between October 2010 and September 2014 from the National Database of Health Insurance Claims of Japan.

Measures: A composite quality score (QS) of 3 quality measures for CKD care during the 6 months after CKD diagnosis was computed. The validated quality measures included urine testing for proteinuria, nutritional guidance, and nonsteroidal anti-inflammatory drugs avoidance. To assess the association between the QS and ESRD incidence, we used instrumental variable analysis after stratification for the history of diabetes.

Results: Among the 890,773 older CKD patients, 2.9% progressed to ESRD (incidence rate of 12.5 per thousand person-years). In total, 59.9% underwent urine testing, 4.5% received nutritional guidance, and 91.2% avoided regular use of nonsteroidal anti-inflammatory drugs. An instrumental variable analysis revealed that a higher QS was associated with-lower ESRD incidence in patients diagnosed with diabetes (hazard ratio: 0.25, 95% confidence interval: 0.24-0.27 for each point higher score) but not in patients without a diagnosis of diabetes (hazard ratio: 0.99, 95% confidence interval: 0.92-1.05).

Conclusion: Among older CKD patients, quality of CKD care varied between patients, and better quality of CKD care was associated with a lower ESRD incidence in patients with diabetes but not in nondiabetic patients.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Cohort Studies
  • Female
  • Humans
  • Incidence*
  • Japan / epidemiology
  • Kidney Failure, Chronic / epidemiology*
  • Male
  • Middle Aged
  • Quality of Health Care / standards*
  • Quality of Health Care / statistics & numerical data
  • Renal Insufficiency, Chronic / epidemiology
  • Renal Insufficiency, Chronic / therapy*
  • Risk Factors