56% of VA patients with diabetes and CKD stages 3-5 filled at least one prescription for either an ACE inhibitor or an ARB in 2018
Veteran’s Affairs (VA) data presented are from a national sample of health care visits to the VA Health System by eligible U. S. veterans. During any given year, ~ 70% of the outpatient population receives a serum creatinine test. While the demographics of VA Health System users are distinct from the general U.S. population, the VA data allow a ‘snapshot’ of clinical practices across the nation.
National VA data were examined for veterans with at least one outpatient visit during the federal fiscal year. To estimate prevalence of CKD, outpatient serum creatinine laboratory results (averaged if a patient had more than one test during the fiscal year) were used to calculate an estimated glomerular filtration rate (eGFR) for each patient using the CKD-EPI equation, excluding dialysis and transplant patients. Estimated GFR (kidney function) was classified into five CKD categories (eGFR =90, eGFR 60-89, stage 3=eGFR 30-59, stage 4=eGFR 15 to 29, and stage 5 without dialysis=eGFR<15 ml/min/1.73 m² and “eGFR Unmeasured” for those patients without serum creatinine testing. Inpatient serum creatinine data were not used as they would be affected by the presence of acute illnesses. Due to the infrequency of testing, albuminuria was not included in the definition of CKD. Dialysis patients were defined by clinic stop-codes (602-611), outpatient procedure codes for dialysis (CPT4: 90921 and 90925), outpatient diagnosis codes (ICD-9-CM: 585.6, V56, V45.1 and E87.91 and ICD-10-CM: N186, Y841, Z4931, Z4901, Z4902, Z4931, Z4932, and Z4933) to indicate dialysis. Kidney transplant patients were identified by inpatient and outpatient ICD-9-CM diagnosis code V420, 99681, ICD-10 CM diagnosis code T86X, Z4822 and Z940, and inpatient procedure and surgery codes (55.69).
Outpatient VA pharmacy records of prescriptions filled for patients were examined for drugs in the angiotensin converting enzyme (ACE) inhibitor and angiotensin II receptor blockcade (ARB) classes.
This material is the result of work supported with resources and the use of facilities at the Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan.
|Description of Measure||Percentage of patients with diabetes mellitus and chronic kidney disease in Stages 3-5 that filled at least one prescription for an ACE inhibitor or an ARB within the specified fiscal year through the VA pharmacy.|
|Type of Data Source||Administrative Data|
|Data Set||VA National Data, using the MedSAS data files|
|Health Care System Data||Yes|
|Regional or National?||National|
|Demographic Group||Patients using the VA health care system|
|Numerator||Patients in the denominator with a record of at least one filled prescription for an ACE inhibitor or an ARB during the specified fiscal year|
with a serum creatinine result during the given fiscal year that yielded an
eGFR of less than 60 ml/min/1.73m2 that were not on dialysis or a
transplant recipient (chronic kidney disease stages 3-5) and diabetes mellitus
(determined by diagnosis, medication use and lab tests, if available).|
|Glomerular Filtration Rate|
Estimated using the CKD-EPI equation: eGFR=141 X min(SCR/K,1)**A X max(SCR/K,1)**-1.209 X 0.993**Age X 1.018[if female] X 1.159[if black] where SCR is serum creatinine in mg/dl, min is the minimum of SCR/K or 1, max is the maximum of SCR/K or 1, K=0.7 for female or K=0.9 for male, A is -.329 for female and -.411 for male. Missing race/ethnicity was coded as white. ** signifies "raised to the power of".
A valid serum creatinine value was defined as 0.3-15.0 mg/dl. Any values outside of this range were set to missing. No more than 1% of serum creatinine values in each cohort were outside of this range.
|Diabetes Melllitus Status||Diabetes mellitus status determined by inpatient or outpatient diagnosis (ICD-9-CM code), outpatient lab test results for hemoglobin A1c (6.5 or higher) or glucose (200 or higher) and/or the filling of an outpatient prescription for diabetes medication through the VA pharmacy.|
|Drugs in ACE Inhibitor and ARB classes|
Angiotensin Converting Enzyme (ACE) Inhibitors:
Angiotensin II Receptor Blockers (ARBs):
|Primary Data Source Indicator||Filled prescription for an ACE inhibitor or ARB.|
|Secondary (1) Variable||Age as of January 1 of specified year|
|Secondary (1) Variable Method of Measurement||Date of birth available for each outpatient visit. If multiple dates of birth are reported, the most frequently reported date of birth was used.|
|Secondary (2) Variable||Gender|
|Secondary (2) Variable Method of Measurement||Patient gender is available for each outpatient visit. If both male and female are reported, the most frequently reported gender was used.|
|Secondary (3) Variable||Race/Ethnicity|
|Secondary (3) Variable Method of Measurement||Race and ethnicity available for each outpatient (up to 7 values) and inpatient (up to 6 values) visit. If multiple race/ethnicity combinations are reported, the most frequently reported was used. To combine race and ethnicity into one category, a patient was designated Hispanic if they reported Hispanic ethnicity and white, black/African American, or unknown/missing race. If a patient of Hispanic ethnicity reported American Indian, Native Alaskan, Pacific Islander, Native Hawaiian, or Asian as their race, they were classified in their race group rather than as Hispanic.|
References and Sources:
Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int. 2013;3(Suppl 1):1-150.
National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification and stratification. Am J Kidney Dis. 2002;39(2)(Suppl 1):S1-S266.