A National Surveillance Project on CKD Management in the Canadian Primary Care: Overview and representativeness

Bello, AK (NPI); Ronksley, PE; Tangri, N; Singer, A; Grill, A; Nitsch, D; Queenan, JA; Lindeman, C; Soos, L; Freiheit, E; Mangin, D; Drummond, D.


Although healthcare is provincially/territorially administered in Canada, existing national networks such as the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) are facilitators for the conduct of nationally-based quality improvement (QI)-based studies to improve chronic kidney disease (CKD) care.


1) Determine the current practice pattern on risk identification and process of care for CKD based on established quality indicators, and 2) investigate the care variation across patients and provider demographics, and regional characteristics (intra and inter provincial/territorial variation).


The CPCSSN is the first pan-Canadian multi-disease surveillance system (collects health information from the primary care EMRs in eight out of the ten provinces and one territory). The data repository contains health information on 1.5 million Canadians. The initial focus of the CPCSSN was to conduct surveillance on eight chronic conditions (diabetes, hypertension, osteoarthritis, COPD, depression, dementia, epilepsy and Parkinson’s disease). The current initiative is targeted to including CKD in the list of chronic conditions for surveillance.


The CPCSSN database was used to develop a cohort of CKD patients being managed in primary care between January 1, 2010 and December 31, 2015. In this cohort, we identified 3,060,836 and 534, 823 available serum creatinine and urine albumin measurements respectively. There were ~381,000 urine albumin measurements in individuals with diabetes compared to ~154,000 measures in those without diabetes. The availability and spread of the measures of kidney function (serum creatinine) and albuminuria that defined CKD are comprehensive across multiple timeframes and disease conditions. Geographical coverage was uniform across participating provinces/territory and sentinels.


To our knowledge, this represents the largest cohort to estimate the burden and quality of care of CKD care in primary care. The coverage and representativeness of the measures for CKD appears high and represents a huge opportunity for understanding the current practice pattern in CKD management. This has implications on 1)closing the gap between observed and expected burden and risks of CKD, and 2) mapping the standard of care achieved, thereby providing opportunities for focused and effective population-level QI initiatives to enhance CKD care in Canada and beyond.