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James MT, Scory TD, Novak E, Manns BJ, Hemmelgarn BR, Bello AK, Ravani P, Kahlon B, MacRae JM, Ronksley PE. Nurse Practitioner Care Compared with Primary Care or Nephrologist Care in Early CKD. Clin J Am Soc Nephrol 2023; 18:1533-1544. [PMID: 38064305 PMCID: PMC10723919 DOI: 10.2215/cjn.0000000000000305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 09/13/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND Early interventions in CKD have been shown to improve health outcomes; however, gaps in access to nephrology care remain common. Nurse practitioners can improve access to care; however, the quality and outcomes of nurse practitioner care for CKD are uncertain. METHODS In this propensity score-matched cohort study, patients with CKD meeting criteria for nurse practitioner care were matched 1:1 on their propensity scores for ( 1 ) nurse practitioner care versus primary care alone and ( 2 ) nurse practitioner versus nephrologist care. Processes of care were measured within 1 year after cohort entry, and clinical outcomes were measured over 5 years of follow-up and compared between propensity score-matched groups. RESULTS A total of 961 (99%) patients from the nurse practitioner clinic were matched on their propensity score to 961 (1%) patients receiving primary care only while 969 (100%) patients from the nurse practitioner clinic were matched to 969 (7%) patients receiving nephrologist care. After matching to patients receiving primary care alone, those receiving nurse practitioner care had greater use of angiotensin-converting enzyme inhibitors/angiotensin receptor blocker (82% versus 79%; absolute differences [ADs] 3.4% [95% confidence interval, 0.0% to 6.9%]) and statins (75% versus 66%; AD 9.7% [5.8% to 13.6%]), fewer prescriptions of nonsteroidal anti-inflammatory drugs (10% versus 17%; AD -7.2% [-10.4% to -4.2%]), greater eGFR and albuminuria monitoring, and lower rates of all-cause hospitalization (34.1 versus 43.3; rate difference -9.2 [-14.7 to -3.8] per 100 person-years) and all-cause mortality (3.3 versus 6.0; rate difference -2.7 [-3.6 to -1.7] per 100 person-years). When matched to patients receiving nephrologist care, those receiving nurse practitioner care were also more likely to be prescribed angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and statins, with no difference in the risks of experiencing adverse clinical outcomes. CONCLUSIONS Nurse practitioner care for patients with CKD was associated with better guideline-concordant care than primary care alone or nephrologist care, with clinical outcomes that were better than or equivalent to primary care alone and similar to those with care by nephrologists. PODCAST This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_12_08_CJN0000000000000305.mp3.
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Affiliation(s)
- Matthew T. James
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Departments of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Tayler D. Scory
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ellen Novak
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Braden J. Manns
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Departments of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Brenda R. Hemmelgarn
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Aminu K. Bello
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Pietro Ravani
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Departments of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Bhavneet Kahlon
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer M. MacRae
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Departments of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Paul E. Ronksley
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Departments of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
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Beall RF, Leung AA, Quinn AE, Salmon C, Scory TD, Bresee LC, Ronksley PE. Laboratory testing and antihypertensive medication adherence following initial treatment of incident, uncomplicated hypertension: A real-world data analysis. J Clin Hypertens (Greenwich) 2022; 24:1316-1326. [PMID: 36125169 DOI: 10.1111/jch.14567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 08/05/2022] [Accepted: 08/12/2022] [Indexed: 11/29/2022]
Abstract
In this study on medication adherence among newly diagnosed patients with uncomplicated, incident hypertension, we conducted a retrospective cohort study using available administrative and laboratory data from April 1, 2012 to March 31, 2017 in Alberta, Canada to understand the extent to which baseline laboratory assessment and/or subsequent follow-up was associated with persistence with antihypertensive therapy. We determined the frequency of baseline and follow-up testing and compared the rates of medication persistence by patient-, neighbourhood-, and treatment-related factors. Of 103 232 patients with newly diagnosed, uncomplicated hypertension who filled their first prescription within our study timeframe, 52.5% were non-persistent within 6 months. Persistent patients were more often female and residing in neighbourhoods with higher social status (with exception to rurality). Aside from older age, the strongest predictor of persistence was performance of laboratory testing related to hypertension with an apparent effect in which higher levels of medication persistence were seen with more frequent laboratory testing. We concluded that medication persistence was far from optimal, dropping off considerably after 6 months for more than half of patients. Medication persistence is a substantial barrier to realizing the full societal benefits of antihypertensive treatment. Ongoing follow up with patients, including laboratory testing, may be a critical component of better long term treatment persistence.
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Affiliation(s)
- Reed F Beall
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Alexander A Leung
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Amity E Quinn
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Charleen Salmon
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tayler D Scory
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lauren C Bresee
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul E Ronksley
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Lunney M, Ronksley PE, Weaver RG, Barnieh L, Blue N, Avey MT, Rolland-Harris E, Khan FM, Pang JXQ, Rafferty E, Scory TD, Svenson LW, Rodin R, Tonelli M. COVID-19 infection among international travellers: a prospective analysis. BMJ Open 2021; 11:e050667. [PMID: 34168036 PMCID: PMC8228575 DOI: 10.1136/bmjopen-2021-050667] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/01/2021] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES This report estimates the risk of COVID-19 importation and secondary transmission associated with a modified quarantine programme in Canada. DESIGN AND PARTICIPANTS Prospective analysis of international asymptomatic travellers entering Alberta, Canada. INTERVENTIONS All participants were required to receive a PCR COVID-19 test on arrival. If negative, participants could leave quarantine but were required to have a second test 6 or 7 days after arrival. If the arrival test was positive, participants were required to remain in quarantine for 14 days. MAIN OUTCOME MEASURES Proportion and rate of participants testing positive for COVID-19; number of cases of secondary transmission. RESULTS The analysis included 9535 international travellers entering Alberta by air (N=8398) or land (N=1137) that voluntarily enrolled in the Alberta Border Testing Pilot Programme (a subset of all travellers); most (83.1%) were Canadian citizens. Among the 9310 participants who received at least one test, 200 (21.5 per 1000, 95% CI 18.6 to 24.6) tested positive. Sixty-nine per cent (138/200) of positive tests were detected on arrival (14.8 per 1000 travellers, 95% CI 12.5 to 17.5). 62 cases (6.7 per 1000 travellers, 95% CI 5.1 to 8.5; 31.0% of positive cases) were identified among participants that had been released from quarantine following a negative test result on arrival. Of 192 participants who developed symptoms, 51 (26.6%) tested positive after arrival. Among participants with positive tests, four (2.0%) were hospitalised for COVID-19; none required critical care or died. Contact tracing among participants who tested positive identified 200 contacts; of 88 contacts tested, 22 were cases of secondary transmission (14 from those testing positive on arrival and 8 from those testing positive thereafter). SARS-CoV-2 B.1.1.7 lineage was not detected in any of the 200 positive cases. CONCLUSIONS 21.5 per 1000 international travellers tested positive for COVID-19. Most (69%) tested positive on arrival and 31% tested positive during follow-up. These findings suggest the need for ongoing vigilance in travellers testing negative on arrival and highlight the value of follow-up testing and contact tracing to monitor and limit secondary transmission where possible.
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Affiliation(s)
- Meaghan Lunney
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul E Ronksley
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert G Weaver
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lianne Barnieh
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Norman Blue
- Office of the Chief Medical Officer of Health, Alberta Health, Government of Alberta, Edmonton, Alberta, Canada
| | - Marc T Avey
- Public Health Agency of Canada, Ottawa, Ontario, Canada
| | | | - Faisal M Khan
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jack X Q Pang
- Provincial Population and Public Health, Alberta Health Services, Calgary, Alberta, Canada
| | - Ellen Rafferty
- Analytics & Performance Reporting Branch, Alberta Health, Government of Alberta, Edmonton, Alberta, Canada
- Institute of Health Economics, Edmonton, Alberta, Canada
| | - Tayler D Scory
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lawrence W Svenson
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Analytics & Performance Reporting Branch, Alberta Health, Government of Alberta, Edmonton, Alberta, Canada
- Division of Preventive Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Rachel Rodin
- Public Health Agency of Canada, Ottawa, Ontario, Canada
| | - Marcello Tonelli
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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