Date Published: July 28, 2017
Publisher: Public Library of Science
Author(s): Paithoon Sonthon, Supannee Promthet, Siribha Changsirikulchai, Ram Rangsin, Bandit Thinkhamrop, Suthee Rattanamongkolgul, Cameron P. Hurst, Cheng Hu.
The present study investigates the impact of quality of care (QoC) and other factors on chronic kidney disease (CKD) stage progression among Type 2 Diabetes Mellitus (T2DM) patients.
This study employed a retrospective cohort from a nationwide Diabetes and Hypertension study involving 595 Thai hospitals. T2DM patients who were observed at least 2 times in the 3 years follow-up (between 2011–2013) were included in our study. Ordinal logistic mixed effect regression modeling was used to investigate the association between the QoC and other factors with CKD stage progression.
After adjusting for covariates, we found that the achievement of the HbA1c clinical targets (≤7%) was the only QoC indicator protective against the CKD stage progression (adjusted OR = 0.76; 95%CI = 0.59–0.98; p<0.05). In terms of other covariates, age, occupation, type of health insurance, region of residence, HDL-C, triglyceride, hypertension and insulin sensitizer were also strongly associated with CKD stage progression. This cohort study demonstrates the achievement of the HbA1c clinical target (≤7%) is the only QoC indicator protective against progression of CKD stage. Neither of the other clinical targets (BP and LDL-C) nor any process of care targets could be shown to be associated with CKD stage progression. Therefore, close monitoring of blood sugar control is important to slow CKD progression, but long-term prospective cohorts are needed to gain better insights into the impact of QoC indicators on CKD progression.
Chronic kidney disease (CKD) is a major problem in both developing and developed countries and is associated with a substantial burden in terms of mortality, morbidity, and health care costs [1–3]. Type 2 diabetes mellitus (T2DM) is the leading cause of CKD worldwide and the prevalence of CKD in T2DM patients is 43.5% in the US , 38% in Belgium , 34.7% in Finland  and 22.9% in the Mediterranean area . Furthermore, CKD patients have 2 to 4 times the risk of cardiovascular disease , and 3 times the risk of mortality relative to T2DM patients without CKD . Also, quality of life has been shown to be negatively associated with CKD .
Of the total number of patients in the Thai DMHT study, 3,313(9.01%) patients had 2 or more observations (collectively, 6,731 observations) and were subsequently included in the present study (Fig 1). To assess whether our sample (patients with at least two observations) is representative of the full T2DM dataset (all T2DM patients), we compared patients with repeated observation with the 67,977 patients only observed once (Table 1). For the most part, patients with a single observations were similar to those with repeated observations. For example, there was less than 1 percent fewer patients with repeated observations who achieved the blood pressure clinical target (Table 2). However, there was some difference (3.26%) in the achievement of HbA1c control between patients with a single observation, and those with repeated observations.
CKD represents a major problem as it is associated with a substantial burden in term of mortality , morbidity  and health care costs . The prevalence of CKD among T2DM patients is increasing rapidly worldwide , especially in UMIC (upper middle-income countries) like Thailand  and improving the diabetes quality of care in T2DM patients is a strategy to attenuate the CKD problem [11,20]. Our review of the CKD literature found no previous study that has considered CKD stage progression in the Asian population. Furthermore, studies that have considered progression in the other populations do not consider progression through CKD stages as defined by 2012KDIGO. Instead, these studies have focused on a dichotomized measure of progression (progress/ no progress). To the best of our knowledge, our study represents the first study, in any population, to model progression through the 2012KDIGO stages.
This cohort study demonstrates the achievement of the HbA1c clinical target (≤7%) was the only clinical target protective against progression of CKD stage. Neither of the other clinical targets, BP and LDL-C, could be shown to be associated with progression of CKD stage. Furthermore, we could not demonstrate that processes of care indicators to be associated with progression of CKD stage. Our study demonstrates the HbA1c target achievement is a strong indicator of CKD stage progression, and CKD patients should be closely monitoring for blood sugar control. Furthermore, staging of CKD should include Albuminuria along with eGFR. Further study of long-term, prospectively-collected cohorts to gain better into the impact of QoC indicators on CKD progression.