Primary Care

Preventive health care could be improved for patients with chronic kidney disease who are receiving renal dialysis

Patients with chronic kidney disease (CKD) do not have adequate preventive health care screenings prior to beginning renal dialysis. Screening becomes even less adequate after starting dialysis (renal replacement therapy), even though dialysis requires regular and frequent contact with health care professionals. As patients approach and undergo dialysis, the health care they receive revolves predominantly around preparation for and delivery of the dialysis (for example, prevention of anemia), and preventive health care may fall through the cracks.

To avoid this and improve the health of these vulnerable patients, the relationship between the nephrologist (or dialysis facility) and the primary care provider needs to be highly functional, according to researchers at Brigham and Women's Hospital, Harvard Medical School, and Duke University Medical Center. Their research was supported in part by the Agency for Healthcare Research and Quality (HS09398). They examined the use of five preventive care screenings from 1990 to 1996 among 3,014 New Jersey Medicaid and Medicare patients with CKD at 1 year before and after beginning dialysis. The screening tests included mammography, Pap smears, prostate cancer screening, diabetic eye exams (since many long-term diabetics develop CKD), and glycosylated hemoglobin testing (to measure blood sugar levels among diabetics).

With the exception of diabetic eye exams, 40 percent or fewer patients received recommended preventive care screening. The mammography screening rate for women aged 52 to 69 years was 27 percent before dialysis and 26 percent during the first year of dialysis. For women aged 21 to 64 years, cervical cancer screening was 17 percent the year before dialysis and 21 percent during the first year of dialysis. Prostate cancer screening, diabetic eye exams, and glycosylated hemoglobin testing were performed less often after onset of dialysis compared with the year before (27 vs. 40 percent, 76 vs 81 percent, and 11 vs. 19 percent, respectively).

More details are in "Preventive health care measures before and after start of renal replacement therapy," by Wolfgang C. Winkelmayer, M.D., Sc.D., William Owen Jr., M.D., Robert J. Glynn, Sc.D., and others, in the August 2002 Journal of General Internal Medicine 17, pp. 588-595.

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