Examining variations in adherence to guideline-recommended post-acute kidney injury care in primary care in England: a population-based cohort study

Abstract

Abstract Background Acute kidney injury (AKI) is a clinical syndrome characterised by a sudden deterioration of kidney function. It is common and usually occurs as a complication of severe illness or major surgery. Despite the high risk of complications and a decade of improvement initiatives in the UK, little is known about the quality of post-discharge AKI care. Our population-based cohort study investigated adherence to guideline-recommended post-AKI care in general practices in England. Methods Using English hospital admission data (2017–2021), we created a cohort of discharged patients (≥ 18 years) with a hospital diagnostic code of AKI. Using linked Clinical Practice Research Datalink Aurum primary care data, we examined percentages of AKI episodes meeting the criteria of 14 guideline-recommended post-AKI care indicators, covering: AKI coding in primary care, post-discharge primary care contacts, kidney health and blood pressure monitoring, and guideline-indicated prescribing. Variations of indicator adherence according to patient characteristics were quantified using binomial mixed regression. Results 209,222 patients (48.0% females; mean age 74.1 years) were included, representing 279,187 AKI inpatient episodes. Only 19.5% (95% CI 18.5–20.5) of episodes had AKI coded in primary care within 30 days of discharge, while 72.6% (95% CI 71.8–73.4) had a documented contact with general practice. At 90 ± 30 days after discharge, serum creatinine was measured in 34.2% (95% CI 33.7–34.8) of episodes, blood pressure in 34.6% (95% CI 34.0-35.1), and albumin-creatinine ratio in 4.2% (95% CI 4.0-4.4). Testing was less common amongst younger patients and those without comorbid conditions. Renin-angiotensin system inhibitor prescribing rates were low in patients likely to benefit. Conclusions There are multiple missed opportunities for improving post-AKI care. Rates of measuring albuminuria were particularly low, despite its strong association with subsequent kidney and cardiovascular events. The limited post-AKI clinical activity amongst younger patients and those without comorbidities undermines the prevention and early intervention of chronic kidney diseases. Clearer discharge arrangements, including case-specific guidance on discharge summaries, and the development and evaluation of concerted implementation strategies spanning secondary and primary care are needed.