Inequalities in CKD management can be overcome

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Molokhia et al¹ report on chronic kidney disease (CKD) coding in primary care records in a multi-ethnic area of South London, demonstrating lower rates in all ethnic minority groups compared with the white population, which contributes to health inequalities. They also confirm the findings based on the National Chronic Kidney Disease audit^2,3 that absence of CKD coding is associated with worse outcomes for blood pressure management and statin prescribing, and is associated with a greater burden of non-steroidal anti-inflammatory drug (NSAID) prescribing.

However, their study was based on a primary care dataset from 2013. Is it possible that Lambeth practices have improved coding rates since then? In East London there were similar low rates of CKD coding prior to 2015, when a quality improvement project promoting coding for CKD as part of a community renal service was introduced.

We combined feedback to practices, using quarterly dashboards to show performance relative to others, and engaged with the clinical commissioning groups (CCGs) to include CKD coding in Local Enhanced Services contracts. Over a 2-year period we showed a sustained rise in CKD coding to >85% across all the CCGs involved in the programme.⁴

Table 1 shows the dashboard for Newham CCG (with 7822 CKD cases) from July 2020. It illustrates the high rates of coding across all age bands and all ethnic groups, with the highest recording rates in black African and black Caribbean. Results are similar across all participating CCGs.

Table 1.

Newham CCG dashboard, July 2020

		CKD cases, n	Diabetes comorbidity, %	Hypertension comorbidity, %	CKD, coded, %	Prescribed statin, %
Age band,a years	18–39	94	13.8	44.7	79.8	20.2
	40–59	1268	32.9	59.8	80.2	52.8
	60–79	3847	48.3	75.7	86.4	77.3
	≥80	2257	45.5	85.4	91.3	74.7
Ethnic group	White	2971	29.1	70.0	85.0	66.9
	South Asian	3251	56.5	76.7	87.8	78.8
	Black	1163	49.3	87.7	90.5	65.6
	Other	327	48.6	74.9	83.2	74.3
	Not recorded	109	26.6	67.9	72.5	56.0

^aData missing. CCG = clinical commissioning group. CKD = chronic kidney disease.

This demonstrates the effectiveness of quality improvement programmes, which can improve the reach of effective interventions and decrease the corrosive effects of health inequalities.

There are further improvements to be made in East London — particularly in the offer of statins to younger people with CKD and improving BP control in those with both diabetes and CKD.

Using the opportunities to work across sectors and incentivise primary care in this way can reduce the impact of cardiovascular and end-stage kidney disease for those ethnic minorities at greatest risk.