{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,10]],"date-time":"2026-08-10T14:41:16Z","timestamp":1786372876541,"version":"build-2736575974"},"reference-count":28,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"12","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["CJASN"],"published-print":{"date-parts":[[2018,12]]},"abstract":"<jats:sec>\n                    <jats:title>Background and objectives<\/jats:title>\n                    <jats:p>Facility-level variation has been reported among veterans receiving care for various diseases. We studied the frequency and facility-level variations of guideline-recommended practices in patients with diabetes and CKD.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design, setting, participants, &amp; measurements<\/jats:title>\n                    <jats:p>\n                      Patients with diabetes and concomitant CKD (eGFR 15\u201359 ml\/min per 1.73 m\n                      <jats:sup>2<\/jats:sup>\n                      , measured twice, 90 days apart) receiving care in 130 facilities across the Veterans Affairs Health Care System were included (\n                      <jats:italic toggle=\"yes\">n<\/jats:italic>\n                      =281,223). We studied the proportions of patients (facility-level) receiving recommended core measures and facility-level variations of these study outcomes using median rate ratios, adjusting for various patient and provider-level factors. Median rate ratio quantifies the degree to which care may vary for similar patients receiving care at two randomly chosen facilities, with &lt;1 being no variation and &gt;1.2 as substantial variation between the facilities. Study outcomes included measurement of urine albumin-to-creatinine ratio\/urine protein-to-creatinine ratio and blood hemoglobin concentration, prescription of statins and angiotensin-converting enzyme inhibitors\/angiotensin receptor blockers, BP&lt;140\/90 mm Hg, and referral to a Veterans Affairs nephrologist (only for those with eGFR&lt;30 ml\/min per 1.73 m\n                      <jats:sup>2<\/jats:sup>\n                      ).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Among those with eGFR 30\u201359 ml\/min per 1.73 m\n                      <jats:sup>2<\/jats:sup>\n                      , proportion of patients receiving recommended core measures (median and interquartile range across facilities) were 37% (22%\u201347%) for urine albumin-to-creatinine ratio\/urine protein-to-creatinine ratio, 74% (72%\u201379%) for hemoglobin measurement, 66% (62%\u201369%) for angiotensin-converting enzyme inhibitor\/angiotensin receptor blocker prescription, 85% (74%\u201387%) for statin prescription, 47% (42%\u201353%) for achieving BP&lt;140\/90 mm Hg, and 13% (7%\u201316%) for meeting all outcome measures. Adjusted median rate ratios (95% confidence intervals) were 5.2 (4.1 to 6.4), 2.4 (2.1 to 2.6), 1.3 (1.2 to 1.3), 1.2 (1.2 to 1.3), 1.4 (1.3 to 1.4), and 4.1 (3.3 to 5.0), respectively. Median rate ratios were qualitatively similar in an analysis restricted to those with eGFR 15\u201329 ml\/min per 1.73 m\n                      <jats:sup>2<\/jats:sup>\n                      .\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Among patients with diabetes and CKD, at facility-level, ordering of laboratory tests, and scheduling of nephrology referrals in eligible patients remains suboptimal, with substantial variations across facilities.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.2215\/cjn.03830318","type":"journal-article","created":{"date-parts":[[2018,11,29]],"date-time":"2018-11-29T16:09:15Z","timestamp":1543507755000},"page":"1842-1850","source":"Crossref","is-referenced-by-count":27,"title":["Facility-Level Variations in Kidney Disease Care among Veterans with Diabetes and CKD"],"prefix":"10.2215","volume":"13","author":[{"given":"Sankar D.","family":"Navaneethan","sequence":"first","affiliation":[{"name":"Selzman Institute for Kidney Health, Section of Nephrology,"},{"name":"Section of Nephrology,"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Julia M.","family":"Akeroyd","sequence":"additional","affiliation":[{"name":"Section of Health Services Research, and"},{"name":"Health Policy, Quality and Informatics Program, Health Services Research and Development Center for Innovations, and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David","family":"Ramsey","sequence":"additional","affiliation":[{"name":"Center for Longitudinal and Lifecourse Research, Faculty of Medicine, University of Queensland, Brisbane, Australia; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah T.","family":"Ahmed","sequence":"additional","affiliation":[{"name":"Health Policy, Quality and Informatics Program, Health Services Research and Development Center for Innovations, and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shiva Raj","family":"Mishra","sequence":"additional","affiliation":[{"name":"Center for Longitudinal and Lifecourse Research, Faculty of Medicine, University of Queensland, Brisbane, Australia; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laura A.","family":"Petersen","sequence":"additional","affiliation":[{"name":"Health Policy, Quality and Informatics Program, Health Services Research and Development Center for Innovations, and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paul","family":"Muntner","sequence":"additional","affiliation":[{"name":"Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christie","family":"Ballantyne","sequence":"additional","affiliation":[{"name":"Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas;"},{"name":"Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wolfgang C.","family":"Winkelmayer","sequence":"additional","affiliation":[{"name":"Selzman Institute for Kidney Health, Section of Nephrology,"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Venkat","family":"Ramanathan","sequence":"additional","affiliation":[{"name":"Selzman Institute for Kidney Health, Section of Nephrology,"},{"name":"Section of Nephrology,"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Salim S.","family":"Virani","sequence":"additional","affiliation":[{"name":"Section of Health Services Research, and"},{"name":"Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas;"},{"name":"Health Policy, Quality and Informatics Program, Health Services Research and Development Center for Innovations, and"},{"name":"Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas;"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","published-online":{"date-parts":[[2018,11,29]]},"reference":[{"key":"B1-20230813","doi-asserted-by":"crossref","first-page":"473","DOI":"10.7326\/M16-0273","article-title":"Trends in prevalence of chronic kidney disease in the United States.","volume":"165","author":"Murphy","year":"2016","journal-title":"Ann Intern Med"},{"key":"B2-20230813","doi-asserted-by":"crossref","first-page":"807","DOI":"10.1016\/S0140-6736(12)60572-8","article-title":"Risk of coronary events in people with chronic kidney disease compared with those with diabetes: A population-level cohort study.","volume":"380","author":"Tonelli","year":"2012","journal-title":"Lancet"},{"issue":"Suppl 10","key":"B3-20230813","first-page":"S163","article-title":"All-cause costs increase exponentially with increased chronic kidney disease stage.","volume":"23","author":"Golestaneh","year":"2017","journal-title":"Am J Manag Care"},{"issue":"Suppl 2","key":"B4-20230813","doi-asserted-by":"crossref","first-page":"B45","DOI":"10.2337\/diacare.27.suppl_2.B45","article-title":"Diabetes and renal disease in veterans.","volume":"27","author":"Young","year":"2004","journal-title":"Diabetes Care"},{"key":"B6-20230813","doi-asserted-by":"crossref","first-page":"705","DOI":"10.1053\/j.ajkd.2017.06.025","article-title":"Receipt of nephrology care and clinical outcomes among veterans with advanced CKD.","volume":"70","author":"Fung","year":"2017","journal-title":"Am J Kidney Dis"},{"key":"B7-20230813","doi-asserted-by":"crossref","first-page":"22","DOI":"10.1053\/j.ackd.2016.11.005","article-title":"Targeting access to kidney care via telehealth: The VA experience.","volume":"24","author":"Crowley","year":"2017","journal-title":"Adv Chronic Kidney Dis"},{"issue":"Suppl 3","key":"B8-20230813","doi-asserted-by":"crossref","first-page":"S78","DOI":"10.1053\/j.ajkd.2008.07.051","article-title":"CKD screening and management in the Veterans Health Administration: The impact of system organization and an innovative electronic record.","volume":"53","author":"Patel","year":"2009","journal-title":"Am J Kidney Dis"},{"key":"B9-20230813","doi-asserted-by":"crossref","first-page":"185","DOI":"10.1002\/clc.22503","article-title":"Statin use and its facility-level variation in patients with diabetes: Insight from the veterans affairs national database.","volume":"39","author":"Pokharel","year":"2016","journal-title":"Clin Cardiol"},{"key":"B10-20230813","doi-asserted-by":"crossref","first-page":"1055","DOI":"10.1002\/clc.22769","article-title":"Facility-level variation in diabetes and blood pressure control in patients with diabetes: Findings from the Veterans Affairs national database.","volume":"40","author":"Rehman","year":"2017","journal-title":"Clin Cardiol"},{"key":"B11-20230813","doi-asserted-by":"crossref","first-page":"209","DOI":"10.1089\/pop.2017.0090","article-title":"Health care resource utilization for outpatient cardiovascular disease and diabetes care delivery among advanced practice providers and physician providers in primary care.","volume":"21","author":"Virani","year":"2018","journal-title":"Popul Health Manag"},{"key":"B12-20230813","doi-asserted-by":"crossref","first-page":"604","DOI":"10.7326\/0003-4819-150-9-200905050-00006","article-title":"A new equation to estimate glomerular filtration rate.","volume":"150","author":"Levey","year":"2009","journal-title":"Ann Intern Med"},{"key":"B13-20230813","doi-asserted-by":"crossref","first-page":"21","DOI":"10.1016\/j.amjcard.2014.09.041","article-title":"Gender disparities in evidence-based statin therapy in patients with cardiovascular disease.","volume":"115","author":"Virani","year":"2015","journal-title":"Am J Cardiol"},{"key":"B14-20230813","doi-asserted-by":"crossref","first-page":"1253","DOI":"10.1016\/j.amjmed.2015.05.027","article-title":"Implications for ezetimibe therapy use based on IMPROVE-IT criteria.","volume":"128","author":"Virani","year":"2015","journal-title":"Am J Med"},{"key":"B15-20230813","first-page":"61","article-title":"Comparison of the predictive validity of diagnosis-based risk adjusters for clinical outcomes.","volume":"43","author":"Petersen","year":"2005","journal-title":"Med Care"},{"key":"B16-20230813","doi-asserted-by":"crossref","first-page":"111","DOI":"10.1016\/j.jacc.2014.10.035","article-title":"Frequency and practice-level variation in inappropriate aspirin use for the primary prevention of cardiovascular disease: Insights from the National Cardiovascular Disease Registry\u2019s Practice Innovation and Clinical Excellence registry.","volume":"65","author":"Hira","year":"2015","journal-title":"J Am Coll Cardiol"},{"key":"B18-20230813","doi-asserted-by":"crossref","first-page":"1368","DOI":"10.1016\/j.jacc.2016.06.048","article-title":"Practice-level variation in statin use among patients with diabetes: Insights from the PINNACLE registry.","volume":"68","author":"Pokharel","year":"2016","journal-title":"J Am Coll Cardiol"},{"key":"B19-20230813","doi-asserted-by":"crossref","first-page":"743","DOI":"10.1016\/j.gie.2012.06.022","article-title":"Practice patterns of surveillance endoscopy in a Veterans Affairs database of 29,504 patients with Barrett\u2019s esophagus.","volume":"76","author":"El-Serag","year":"2012","journal-title":"Gastrointest Endosc"},{"key":"B20-20230813","doi-asserted-by":"crossref","first-page":"805","DOI":"10.1016\/j.ahj.2015.07.016","article-title":"Variation in use of echocardiography among veterans who use the Veterans Health Administration vs Medicare.","volume":"170","author":"Kini","year":"2015","journal-title":"Am Heart J"},{"key":"B21-20230813","first-page":"1","article-title":"KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease.","volume":"3","year":"2013","journal-title":"Kidney Int Suppl"},{"key":"B24-20230813","doi-asserted-by":"crossref","first-page":"402","DOI":"10.1053\/j.ajkd.2016.03.414","article-title":"The CKD outcomes and practice patterns study (CKDopps): Rationale and methods.","volume":"68","author":"Mariani","year":"2016","journal-title":"Am J Kidney Dis"},{"key":"B25-20230813","doi-asserted-by":"crossref","first-page":"2073","DOI":"10.1016\/S0140-6736(10)60674-5","article-title":"Association of estimated glomerular filtration rate and albuminuria with all-cause and cardiovascular mortality in general population cohorts: A collaborative meta-analysis.","volume":"375","author":"Matsushita","year":"2010","journal-title":"Lancet"},{"issue":"Suppl 1","key":"B26-20230813","first-page":"S11","article-title":"Standards of medical care in diabetes--2013.","volume":"36","year":"2013","journal-title":"Diabetes Care"},{"key":"B27-20230813","doi-asserted-by":"crossref","first-page":"182","DOI":"10.7326\/M13-2453","article-title":"Lipid management in chronic kidney disease: Synopsis of the Kidney Disease: Improving Global Outcomes 2013 clinical practice guideline.","volume":"160","author":"Tonelli","year":"2014","journal-title":"Ann Intern Med"},{"key":"B28-20230813","doi-asserted-by":"crossref","first-page":"1269","DOI":"10.1161\/HYP.0000000000000066","article-title":"2017 ACC\/AHA\/AAPA\/ABC\/ACPM\/AGS\/APhA\/ASH\/ASPC\/NMA\/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: Executive summary: A report of the american college of cardiology\/american heart association task force on clinical practice guidelines.","volume":"71","author":"Whelton","year":"2018","journal-title":"Hypertension"},{"issue":"Suppl 1","key":"B29-20230813","doi-asserted-by":"crossref","first-page":"459","DOI":"10.1111\/1475-6773.12633","article-title":"Veterans\u2019 location in health professional shortage areas: Implications for access to care and workforce supply.","volume":"52","author":"Doyle","year":"2017","journal-title":"Health Serv Res"},{"key":"B31-20230813","doi-asserted-by":"crossref","first-page":"318","DOI":"10.1038\/ki.2009.158","article-title":"When laboratories report estimated glomerular filtration rates in addition to serum creatinines, nephrology consults increase.","volume":"76","author":"Jain","year":"2009","journal-title":"Kidney Int"},{"key":"B32-20230813","first-page":"e57","article-title":"Predialysis nephrology care among older veterans using Department of Veterans Affairs or Medicare-covered services.","volume":"16","author":"Fischer","year":"2010","journal-title":"Am J Manag Care"},{"key":"B33-20230813","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1186\/1472-6947-12-69","article-title":"Implementation of automated reporting of estimated glomerular filtration rate among Veterans Affairs laboratories: A retrospective study.","volume":"12","author":"Hall","year":"2012","journal-title":"BMC Med Inform Decis Mak"}],"container-title":["Clinical Journal of the American Society of Nephrology"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.ovid.com\/01277230-201812000-00013","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,10]],"date-time":"2026-08-10T13:38:52Z","timestamp":1786369132000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.ovid.com\/01277230-201812000-00013"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2018,11,29]]},"references-count":28,"journal-issue":{"issue":"12","published-print":{"date-parts":[[2018]]}},"URL":"https:\/\/doi.org\/10.2215\/cjn.03830318","relation":{},"ISSN":["1555-9041","1555-905X"],"issn-type":[{"value":"1555-9041","type":"print"},{"value":"1555-905X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2018,11,29]]}}}