News Release

Facility-level variations in diabetic kidney disease care within the VA health system

Peer-Reviewed Publication

American Society of Nephrology


  • Concerning adherence to certain recommended measures of kidney disease care for veterans with diabetes within the Veterans Affairs Health Care System, there is modest facility-level variation for some measures and larger facility-level variation for others.

Washington, DC (November 29, 2018) -- A new study has uncovered variation across facilities in the Veterans Affairs (VA) Health System concerning the delivery of key measures of kidney disease care for veterans with diabetes. The findings, which appear in an upcoming issue of the Clinical Journal of the American Society of Nephrology (CJASN), point to areas where care might be improved and standardized among facilities.

The VA Health System is the largest integrated health care system in the United States, and several programs have been implemented to improve the quality of care delivered through the health system to patients with chronic kidney disease (CKD). To assess the extent to which care for patients with CKD varies across different VA facilities, Sankar Navaneethan, MD, MS, MPH (Baylor College of Medicine) and his colleagues examined information on 281,233 patients with diabetes and concomitant CKD receiving care in 130 facilities across the VA Health Care System in 2013-2014.

Among those with stage 3 CKD, the median proportions of patients receiving guideline-recommended core measures were 37% for urine albumin:creatinine ratio/urine protein:creatinine ratio, 74% for hemoglobin measurement, 66% for angiotensin converting enzyme inhibitor/angiotensin receptor blocker prescriptions, 85% for statin prescriptions, 47% for achieving blood pressure <140/90 mm Hg, and 13% for meeting all outcome measures. The investigators also found considerable variation across facilities.

"Despite the ongoing best efforts to improve the care for veterans with diabetes and kidney disease, adherence to guideline-recommended core measures such as ordering of certain laboratory tests, and scheduling of referrals to kidney specialists in eligible patients remains suboptimal, with modest facility-level variations for some measures and larger facility-level variation for others. It is important to note that these rates are similar, if not better than other health care systems," said Dr. Navaneethan. "Our results point out potential areas where additional efforts and programs could be implemented to address practice level variations noted among VA facilities."

In an accompanying editorial, Tyler Woodell, MD and Dena Rifkin, MD, MS (University of California, San Diego) note that certain measures are likely practiced with appropriate adherence and variability that reflect patient-centered care, but other measures must improve. "Clinical leaders should review this information, identify potential deficiencies, and defend those situations in which seemingly inappropriate care is actually appropriate," they wrote. "We can then propose solutions such as automated opt-out order sets, clinical reminders, or patient- centered integration of competing demands to improve care delivery in pursuit of the 'right rate.'"


Study co-authors include Julia Akeroyd, MPH, David Ramsey, PhD, Sarah Ahmed, MBBS, MPH, Shiva Raj Mishra, MPH, Laura Petersen, MD, MPH, Paul Muntner, PhD, Christie Ballantyne, MD, Wolfgang Winkelmayer, MD, MPH, ScD, Venkat Ramanathan, MD, and Salim Virani, MD, PhD.

Disclosures: SN has served on the event adjudication committee for clinical trials sponsored by Bayer and Boehringer Ingelheim, served as a consultant for Tricida, and has received investigator-initiated research support from Keryx Pharmaceuticals. PM receives grant support from Amgen Inc. CB received grant/research support (all paid to institution, not individual) fromAbbott Diagnostic,Amarin, Amgen, Esperion, Ionis, Novartis, Pfizer, Regeneron, Roche Diagnostic, Sanofi-Synthelabo, National Institutes of Health, American Heart Association, and American Diabetes Association, and served as a consultant for Abbott Diagnostics, Amarin, Amgen,AstraZeneca*, Boehringer Ingelheim*, Eli Lilly, Esperion, Ionis,Matinas BioPharma Inc., Merck*, Novartis, NovoNordisk, Pfizer*, Regeneron, Roche Diagnostic, and Sanofi-Synthelabo*. WW served as a consultant for Amgen and Relypsa, received honoraria for lectures from Fibrogen, and served as scientific advisory for Akebia, AstraZeneca, Bayer, Daichii-Sankyo, and Vifor Fresenius Medical Care Renal Pharma. All other authors declare no conflicts of interest. *Indicates significant contribution where noted, all others are modest.

The article, entitled "Facility-Level Variations in Kidney Disease Care among Veterans with Diabetes and Chronic Kidney Disease," will appear online at on November 29, 2018, doi: 10.2215/CJN.03830318.

The editorial, entitled "Still asking 'Which Rate is Right?' Years Later," will appear online at on November 29, 2018.

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