Table 1.
Patient Demographics and Performance on Care Metrics, Stratified by 2-Year KFRE Score Category
| Variable | Tangri 2-Year Kidney Failure Risk Equation Category |
||||
|---|---|---|---|---|---|
| Very Low, <3% (n = 13,925) | Low, 3%-9.9% (n = 2,369) | Moderate, 10%-39.9% (n = 1,469) |
High, ≥ 40% (n = 509) | Unknown (n = 43,274) | |
| Demographics | |||||
| Median age, y (Q1, Q3) | 76 (69-82) | 75 (68-83) | 74 (65-81) | 70 (60-79) | 78 (71-86) |
| Female sex, n (%) | 7,220 (51.8%) | 1,067 (45.0%) | 632 (43.0%) | 221 (43.4%) | 25,610 (59.2%) |
| Race, n (%) | |||||
| White | 11,588 (83.2%) | 1,937 (81.8%) | 1,156 (78.7%) | 374 (73.5%) | 38,329 (88.6%) |
| African American | 813 (5.8%) | 142 (6.0%) | 112 (7.6%) | 44 (8.6%) | 1,235 (2.9%) |
| Asian | 389 (2.8%) | 82 (3.5%) | 64 (4.4%) | 29 (5.7%) | 854 (2.0%) |
| Hispanic | 215 (1.5%) | 31 (1.3%) | 21 (1.4%) | 6 (1.2%) | 283 (0.7%) |
| AIAN-HAPI | 23 (0.2%) | 5 (0.2%) | 2 (0.1%) | 2 (0.4%) | 53 (0.1%) |
| Other/declined/unavailable | 897 (6.4%) | 172 (7.3%) | 114 (7.8%) | 54 (10.6%) | 2,520 (5.8%) |
| BMI (kg/m2), n (%) | |||||
| Underweight (<18.5) | 130 (0.9%) | 32 (1.4%) | 13 (0.9%) | 7 (1.4%) | 801 (1.9%) |
| Normal (18.5-24.9) | 2,708 (19.4%) | 526 (22.2%) | 319 (21.7%) | 116 (22.8%) | 11,665 (27.0%) |
| Overweight (25.0-29.9) | 4,661 (33.5%) | 730 (30.8%) | 475 (32.3%) | 147 (28.9%) | 15,220 (35.2%) |
| Obese (≥30.0) | 6,241 (44.8%) | 1,044 (44.1%) | 627 (42.7%) | 232 (45.6%) | 14,392 (33.3%) |
| Unknown | 185 (1.3%) | 37 (1.6%) | 35 (2.4%) | 7 (1.4%) | 1,196 (2.8%) |
| Payor, n (%) | |||||
| Commercial | 994 (7.1%) | 136 (5.7%) | 90 (6.1%) | 24 (4.7%) | 1,898 (4.4%) |
| Medicaid | 186 (1.3%) | 37 (1.6%) | 39 (2.7%) | 14 (2.8%) | 212 (0.5%) |
| Medicare | 5,510 (39.6%) | 786 (33.2%) | 422 (28.7%) | 97 (19.1%) | 11,909 (27.5%) |
| Unknown | 7,235 (52.0%) | 1,410 (59.5%) | 918 (62.5%) | 374 (73.5%) | 29,255 (67.6%) |
| Comorbidities, n (%) | |||||
| Active smoker | 675 (4.8%) | 152 (6.4%) | 100 (6.8%) | 46 (9.0%) | 1,652 (3.8%) |
| Former smoker | 6,158 (44.2%) | 1,058 (44.7%) | 623 (42.4%) | 179 (35.2%) | 16,487 (38.1%) |
| Diabetes | 8,060 (57.9%) | 1,353 (57.1%) | 861 (58.6%) | 300 (58.9%) | 8,400 (19.4%) |
| Hypertension | 12,208 (87.7%) | 2,120 (89.5%) | 1,331 (90.6%) | 452 (88.8%) | 31,963 (73.9%) |
| Congestive heart failure | 2,637 (18.9%) | 758 (32.0%) | 491 (33.4%) | 170 (33.4%) | 7,769 (18.0%) |
| Coronary artery disease | 3,895 (28.0%) | 823 (34.7%) | 501 (34.1%) | 137 (26.9%) | 9,323 (21.5%) |
| ASCVD risk score, n (%) | |||||
| Low (<5%) | 371 (2.7%) | 66 (2.8%) | 49 (3.3%) | 15 (2.9%) | 1,096 (2.5%) |
| Borderline (5%-7.4%) | 243 (1.7%) | 45 (1.9%) | 18 (1.2%) | 8 (1.6%) | 771 (1.8%) |
| Intermediate (7.5%-19.9%) | 1,529 (11.0%) | 170 (7.2%) | 124 (8.4%) | 39 (7.7%) | 4,079 (9.4%) |
| High (20% +) | 2,964 (21.3%) | 420 (17.7%) | 241 (16.4%) | 81 (15.9%) | 4,645 (10.7%) |
| Unknown | 8,818 (63.3%) | 1,668 (70.4%) | 1,037 (70.6%) | 366 (71.9%) | 32,683 (75.5%) |
| Utilization, n (%) | |||||
| In-network PCP | 10,846 (77.9%) | 1,635 (69.0%) | 933 (63.5%) | 273 (53.6%) | 24,488 (56.6%) |
| In-network nephrologist | 5,410 (38.9%) | 1,437 (60.7%) | 954 (64.9%) | 298 (58.5%) | 3,077 (7.1%) |
| CKD stage, n (%) | |||||
| Stage 3A | 7,811 (56.1%) | 97 (4.1%) | 21 (1.4%) | 0 (0.0%) | 26,543 (61.3%) |
| Stage 3B | 5,611 (40.3%) | 1,178 (49.7%) | 247 (16.8%) | 31 (6.1%) | 13,205 (30.5%) |
| Stage 4 | 502 (3.6%) | 1,088 (45.9%) | 1,087 (74.0%) | 250 (49.1%) | 3,047 (7.0%) |
| Stage 5 | 1 (0.0%) | 6 (0.3%) | 114 (7.8%) | 228 (44.8%) | 479 (1.1%) |
| Medications, n (%) | |||||
| ACE-I/ARB | 7,307 (52.5%) | 1,148 (48.5%) | 714 (48.6%) | 221 (43.4%) | 11,707 (27.1%) |
| β-blocker | 7,395 (53.1%) | 1,447 (61.1%) | 935 (63.6%) | 330 (64.8%) | 19,704 (45.5%) |
| Calcium channel blocker | 5,085 (36.5%) | 1,091 (46.1%) | 783 (53.3%) | 304 (59.7%) | 12,319 (28.5%) |
| Diuretics | 6,405 (46.0%) | 1,317 (55.6%) | 861 (58.6%) | 299 (58.7%) | 17,555 (40.6%) |
| Aspirin | 5,907 (42.4%) | 1,071 (45.2%) | 661 (45.0%) | 208 (40.9%) | 10,546 (24.4%) |
| Statin | 8,689 (62.4%) | 1,521 (64.2%) | 950 (64.7%) | 292 (57.4%) | 16,433 (38.0%) |
| CKD care metrics, n (%) | |||||
| Access placement | |||||
| Catheter | 10 (0.1%) | 13 (0.5%) | 10 (0.7%) | 3 (0.6%) | 36 (0.1%) |
| Arteriovenous fistula or graft | 10 (0.1%) | 9 (0.4%) | 32 (2.2%) | 27 (5.3%) | 116 (0.3%) |
| Kidney transplant status | |||||
| Referral | 10 (0.1%) | 5 (0.2%) | 21 (1.4%) | 31 (6.1%) | 46 (0.1%) |
| Evaluation | 8 (0.1%) | 6 (0.3%) | 24 (1.6%) | 20 (3.9%) | 45 (0.1%) |
| Waitlist | 2 (0.0%) | 0 (0.0%) | 2 (0.1%) | 0 (0.0%) | 14 (0.0%) |
| MOLST completed | 1,394 (10.0%) | 293 (12.4%) | 178 (12.1%) | 72 (14.1%) | 5,189 (12.0%) |
| Immunizations | |||||
| Influenza | 7,484 (53.7%) | 1,096 (46.3%) | 645 (43.9%) | 185 (36.3%) | 15,146 (35.0%) |
| Pneumonia | 8,883 (63.8%) | 1,492 (63.0%) | 856 (58.3%) | 264 (51.9%) | 15,795 (36.5%) |
| HBV—immune by titers or vaccination | 1,320 (9.5%) | 259 (10.9%) | 211 (14.4%) | 81 (15.9%) | 2,293 (5.3%) |
| Prescribed medication potentially contraindicated because of kidney function | |||||
| Not applicable (eGFR >30 mL/min/m2) | 13,422 (96.4%) | 1,275 (53.8%) | 268 (18.2%) | 31 (6.1%) | 39,748 (91.9%) |
| No | 334 (2.4%) | 803 (33.9%) | 928 (63.2%) | 367 (72.1%) | 2,600 (6.0%) |
| On potentially unsafe medication | 103 (0.7%) | 189 (8.0%) | 212 (14.4%) | 91 (17.9%) | 645 (1.5%) |
| On unsafe medication (eGFR <30 mL/min/m2) | 66 (0.5%) | 102 (4.3%) | 61 (4.2%) | 20 (3.9%) | 281 (0.6%) |
Abbreviations: ACE-I, Angiotensin-converting enzyme inhibitor; AIAN-HAPI, Alaska Native, American Indian, Hawaiian, or Pacific Islander; ARB, angiotensin receptor blocker; ASCVD, atherosclerotic cardiovascular disease; BMI, body mass index; eGFR, estimated glomerular filtration rate in mL/min/m2; HBV, hepatitis B virus; KFRE, kidney failure risk equation; MOLST, Massachusetts Order for Life-Sustaining Treatment; PCP, primary care provider; PHS, Partners HealthCare System; Q1, 25th percentile; Q3, 75th percentile.