Ongoing gaps in CKD and CVD care: re-evaluating strategies for knowledge dissemination.

Over the last decade, the nephrology community has come to recognize the importance of chronic kidney disease (CKD) as an important modifier of outcomes and of cardiovascular risk. We have attempted to categorize and quantify the risks of dying, having a cardiovascular event and going on to dialysis, and we have published extensively in both nephrology and non-nephrology journals about the importance of CKD in general populations [1–7]. Some jurisdictions have embarked on formal and well-organized education campaigns for general practitioners (GPs) and patients (UK, Canada, Australia, USA) with professional messaging and public campaigns. Guidelines have been written and disseminated [8, 9]. Despite these efforts and the quantity of publications regarding CKD, we have not systematically evaluated the impact of these efforts on quality of care for those persons with CKD. The paper in the current edition of Nephrology Dialysis Transplantation (27/4) by Razavian et al. describes GP awareness of CKD, gaps in treatment and gaps in prescribing in Australia in 2008, after the implementation of estimated glomerular filtration rate (eGFR) reporting by laboratories and 6 years after the publication of the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines for CKD definition, evaluation and classification. The study leveraged the infrastructure of the Australian Hypertension and Absolute Risk Study (AusHEART) and describes cardiovascular risk management in CKD in Australian primary care using a nationally representative, cluster stratified, cross-sectional survey among 322 GPs. Each GP was asked to provide data for 15–20 patients over the age of 55 who presented between April and June 2008. Within the study framework, records on 4966 patients were collected, in whom 37% had abnormal kidney function. The study describes the under-recognition of CKD by GPs (only 18% of the overall CKD cohort were correctly identified, with 67% of those being in Stages 4 and 5 and 28% being Stage 3), under-estimation of cardiovascular disease (CVD) risk in CKD patients and, paradoxically, the overestimation of CVD risk in non-CKD patients. Furthermore, the study identified gaps in achievement of targets for hypertension, use of renin-angiotensin system (RAS) blockade and lipid-lowering agents in CKD patients. The study is meritorious on a number of levels. Firstly, the robust methodology for random sampling of GP practices participating in the AusHEART study, stratified by state and urban/rural locations to reflect the distribution of the Australian adult population, ensures a representative sample of practices. While one may argue that those who volunteered to participate might be the ‘best’ practices, this would only lead to a conservative estimate of the ‘gap’ in knowledge and practice identified in the study. Within that sample, the ability to determine ‘prevalence’ of CKD (albeit using single time point values for eGFR and uACR measurements) adds another important quantitative dimension to the study. Simple one-page questionnaires were given to GPs, which included estimates of CVD risk in each of the patients without specifying how to determine this risk. The authors then compared these GP-generated risks to risk scores generated centrally from Framingham risk equations, which were subsequently adjusted according to two national guidelines that were prevailing at the time of data collection in Australia. This comparison of GP-generated CVD risk compared to ‘formal’ risk equation-generated risk scores allows a unique comparison between GP ‘perception’ and ‘objective’ quantification of risk. The finding that GPs underestimate risk for CVD in CKD patients is surprising given the plethora of data published in highprofile medical journals to the contrary [3, 10, 11]. The documentation of an ‘awareness gap’ as defined by identifying those with CKD correctly (18%) is enlightening for those interested in GP education. The GPs were asked to fill out a ‘yes/no/not known’ CKD question in those in whom laboratory was available at the time of the visit. It is surprising that despite the availability of simple laboratory data, GPs do not identify CKD reliably. Documentation of blood pressure measurements and medications was collected: the prescribing and treatment gap identified was 59% for CKD patients and 52% for nonCKD patients (P < 0.001). This comparison between CKD and non-CKD patients within the same practice is another important aspect of the due diligence of the study: while gaps in care exist in all patients, the treatment of blood pressure (one of the few evidence-based treatments known to impact progression of CKD) is less reliable in those at highest risk. Overwhelmingly, the study points to a large gap in awareness and treatment of CKD patients within a well-supported, resourced and universally accessible health care system.