Association of Preventive Health Care with Atherosclerotic Heart Disease and Mortality in CKD

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Abstract
Chronic kidney disease (CKD, stages 1 to 4) affects approximately 13.1% of United States adults and leads to ESRD, cardiovascular disease, and premature death. Here, we assessed adherence to a subset of Kidney Disease Outcomes Quality Initiative preventive health care guidelines and identified associations between adherence and incident atherosclerotic heart disease (ASHD). Using the Medicare 5% data set, 1999 to 2005 (about 1.2 million patients per year), we created 3-yr rolling cohorts. We classified CKD and diabetes during year 1, assessed preventive care during year 2, and evaluated ASHD outcomes during year 3. We defined preventive care by the receipt of laboratory measurements (serum creatinine, lipids, calcium and phosphorus, parathyroid hormone, and, for patients with diabetes, hemoglobin A1c), influenza vaccination, and by at least one outpatient visit to a nephrologist. Among patients with CKD, 80% received ≥2 serum creatinine tests during the year, and only 11% received parathyroid hormone testing. Cumulative incidence of the combined ASHD outcome was 25% and 11% for patients with and without prevalent cardiovascular disease, respectively. Except for serum creatinine testing, preventive care associated with lower ASHD rates in the subsequent year, ranging from 10% lower for those who received influenza vaccinations and ≥2 A1c tests, to 43% lower for calcium-phosphorus assessment. Receiving ≥2 serum creatinine tests associated with a 13% higher rate of ASHD. A higher number of preventive measures associated with lower rates of ASHD. In summary, these data support an association between preventive measures and reduced cardiovascular morbidity and mortality.