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Experts question QOF definition of kidney disease

Warning of over-diagnosis of chronic kidney disease

Adrian O'Dowd

Wednesday, 31 July 2013

Too many people may be getting labelled wrongly as having chronic kidney disease and receiving inappropriate treatment, according to an analysis published online today in the BMJ.

Experts said there was a danger of over-diagnosing kidney disease by using the definition currently used by NICE and in the GP quality and outcomes framework (QOF).

In 2002, a new US framework for defining and classifying chronic kidney disease was introduced, which defines its as the presence of kidney damage or decreased kidney function for three months or more, irrespective of the cause, and is based largely on laboratory measures.

The framework has been widely embraced by many countries including the UK because it was assumed that earlier detection and treatment would slow progression towards kidney failure, and was updated in 2012.

However, some doctors have raised concerns because the adoption of this definition has resulted in more than 1 in 8 adults (almost 14%) in the US being labeled as having chronic kidney disease and as many as 1 in 6 adults in Australia.

A University of Cardiff study found specialist referrals for chronic kidney disease rose 60% within a single NHS trust covering a population of 560,000 people after the QOF targets were introduced.

The analysis authors said the new definition of kidney disease had labeled around half of people over 70 years of age as having the disease, but low rates of kidney failure suggested many of those diagnosed would never progress to severe disease.

Ray Moynihan, senior research fellow at Bond University, Australia and Richard Glassock, emeritus professor at the Geffen School of Medicine at UCLA, Los Angeles, USA, argued this was evidence of over-diagnosis and called for a re-examination of the definition while urging clinicians to be cautious about labelling patients, particularly older people.

The authors said supporters of the definition claimed that “early detection can help prevent the progression of kidney disease” but they argued this led to over-diagnosis and there was a psychological effect of a disease label and the burden and costs of repeated assessment, testing, and potentially unnecessary treatment.

“The benefits, harms, and costs of testing, monitoring, and treating the increased number of people being identified as having chronic kidney disease need to be established by prospective studies,” said the authors.

“Meanwhile the risk of over-diagnosis warrants greater professional scrutiny and more public awareness. Clinicians should be careful not to apply disease labels to the many older people whose eGFR falls within the definition of chronic kidney disease but who are at very low risk of developing clinical problems.

“It is in everyone’s interest to find the best way to maximise prevention of kidney disease and its consequences while minimising the risks and cost of over-diagnosis.”

DOI:10.1136/bmj.f4298

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