***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: Background  Quality indicators ( QIs ) are an important tool for improving clinical practice and are increasingly being developed from evidence -based guideline recommendations . We aim ed to identify , select and apply guideline recommendations to develop a set of QIs to measure the implementation of evidence -based practice using routinely recorded clinical data in United Kingdom ( UK ) primary care . Methods We review ed existing national clinical guidelines and QIs and used a four-stage consensus development process to derive a set of ‘ high impact ’ QIs relevant to primary care based upon explicit prioritisation criteria . We then field tested the QIs using remotely extracted , anonymised patient records from 89 r and omly sample d primary care practice s in the Yorkshire region of Engl and . Results Out of 2365 recommendations and QIs originally review ed , we derived a set of 18 QIs ( 5 single , 13 composites – comprising 2–9 individual recommendations ) for field testing . QIs predominantly addressed chronic disease management , in particular diabetes , cardiovascular and renal disease , and included both processes and outcomes of care . Field testing proved to be critical for further refinement and final selection . Conclusions We have demonstrated a rigorous and transparent methodology to develop a set of high impact , evidence -based QIs for primary care from clinical guideline recommendations . While the development process was successful in developing a limited set of QIs , it remains challenging to derive robust new QIs from clinical guidelines in the absence of established systems for routine , structured recording of clinical care BACKGROUND Patients with chronic kidney disease ( CKD ) are at significant risk for cardiovascular disease ( CVD ) . The National Kidney Foundation developed clinical practice guidelines ( Kidney Disease Outcomes Quality Initiative ) for targeting low-density lipoprotein cholesterol ( LDL-C ) goals . OBJECTIVE This study evaluated the extent to which these guidelines were adhered to among patients with CKD and to examine factors associated with the attainment of LDL-C goals . METHODS In this cross-sectional study we evaluated patients with a glomerular filtration rate of 15 to 59 mL/min per 1.73 m² . Patients with previous CVD , who were receiving dialysis , or were post kidney transplant were excluded . Administrative data bases were used to determine the percentage of patients with a fasting lipid profile performed within the previous year , the percentage who attained a LDL-C goal less than 100 mg/dL , and to determine lipid-lowering medications prescribed . Logistic regression analysis was used to identify factors associated with LDL-C goal attainment . RESULTS Of the 4541 patients evaluated , 3157 ( 69.5 % ) had a fasting lipid profile performed within the previous year . Overall , 60.8 % attained a LDL-C less than 100 mg/dL. Among patients at goal , 72.2 % were taking lipid-lowering therapy compared with 37.9 % of those not at goal ( P < .01 ) . Characteristics independently associated with LDL-C goal attainment were increasing age , male gender , increasing chronic disease score , history of diabetes , and statin use . CONCLUSION Although most patients were screened and attained LDL-C goal , there was room for improvement . Statin use was independently associated with LDL-C goal attainment . Future prospect i ve studies should focus on evaluating clinical outcomes of lipid-lowering interventions within the CKD population AIMS The study aim ed to assess the prevalence , quality of screening and treatment of chronic kidney disease ( CKD ) , and their trends between 2001 and 2007 , in French adults with type 2 diabetes ( T2D ) . METHODS The 2007 ENTRED survey r and omly selected , from French medical insurance fund data bases , 8926 adults treated for diabetes who had been reimbursed at least three times over the previous 12 months for oral hypoglycaemic agents or insulin .  Medical reimbursement data were extracted and two sets of question naires were mailed , one to all patients ( 48 % response rate ) and the other to their doctors ( 62 % ) . Analyses were restricted to the 3894 responders with T2D ( 2232 with data from their doctors ) . Trends between the 2001 and 2007 ENTRED surveys were studied . RESULTS Participants ' mean age was 66 years . The prevalence of CKD was estimated to be at least 29 % , based on doctors ' data ( missing data included ) . Overall , only 17 % had no cl aims for serum creatinine measurements during the year , and 71 % had no cl aims for albuminuria tests ; nonetheless , both figures had decreased from 2001 . Older people , those who lived alone and those who felt poorly informed about diabetes were more likely to have made no cl aims for CKD screening . Assessment of quality of care ( prescribing antihypertensive treatment when indicated ) was possible for 66 % of responders , of whom 25 % did not receive such treatment . CONCLUSION CKD is frequently seen in patients with T2D and is likely to be underestimated because albuminuria screening remains inadequate , despite significant improvements since 2001 . Further efforts are needed to improve CKD screening , patient and doctor awareness , and adequate use of antihypertensive/nephroprotective medications Cardiovascular disease ( CVD ) is a major cause of morbidity and mortality among patients with chronic renal insufficiency ( CRI ) .  beta-Adrenergic blockers , acetylsalicylic acid ( ASA ) , angiotensin-converting enzyme ( ACE ) inhibitors , and 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors ( statins ) all reduce CVD mortality , but little is known about the extent to which these medications are used in patients with CRI . This study , a prospect i ve cross-sectional study of consecutive patients seen by nephrologists in four Canadian centers for follow-up of progressive CRI in 1999 , was performed to investigate the prevalence of coronary risk factors and use of cardioprotective medications among patients with CRI . Patients had creatinine clearances of 75 mL/min or less but were not on dialysis therapy . Three hundred four consecutive patients meeting the inclusion criteria were enrolled . Mean age was 60.8 + /- 15.7 years , mean creatinine clearance was 30.3 + /- 18 mL/min , and the case mix of kidney diseases was similar to that in the Canadian Organ Replacement Registry data . One hundred seventeen of 304 patients ( 38.5 % ) had a history of previous CVD , and the prevalence of CVD was greater in patients with more severe CRI . Two hundred forty-three patients ( 79.9 % ) had a history of hypertension , 132 patients ( 43.4 % ) had hyperlipidemia , 114 patients ( 37.5 % ) had diabetes mellitus , and 71 patients ( 27.3 % ) were smokers . Thirty-five percent of the patients with CVD had blood pressures greater than 140/90 mm Hg ; 103 patients ( 33.9 % ) were administered beta-blockers ; 196 patients ( 64.5 % ) , ACE inhibitors or angiotensin-receptor blockers ; 83 patients ( 27.3 % ) , ASA ; and 56 patients ( 18.4 % ) , statins . Patients with diabetes were not more likely than those without diabetes to be prescribed cardioprotective medications . CVD is common in the predialysis population , and its prevalence increases with more severe kidney failure . Despite this , the use of cardioprotective medications  is relatively low , and many patients had suboptimal blood pressure control . Given the high burden of disease in these patients , beta-blockers and ACE inhibitors should be used to control hypertension and /or for cardioprotection , and the increased use of ASA and statins should be considered BACKGROUND Current recommendations for the management of chronic renal insufficiency ( CRI ) include the use of angiotensin-converting enzyme inhibitors ( ACEI ) and achieving target blood pressure control . We design ed this study to describe the use of these therapeutic strategies , and to investigate barriers to their implementation . METHODS This was a prospect i ve study of 304 consecutive CRI patients , seen at follow-up in four nephrology clinics across Canada . The use of  blood pressure control and antihypertensive medication ( AHM ) in each of these clinics was recorded , and a question naire was administered to nephrologists to determine the basis for decisions concerning AHM regimens and ACEI use/non-use . RESULTS Mean age was 60.8+/-15.7 years , mean creatinine clearance was 30.3+/-18 ml/min , and underlying renal diseases were similar to registry data .  Mean arterial pressure ( MAP ) achieved was 99.4+/-14.4 and 98.9+/-11.9 mmHg in individuals with > 1 and < /=1 g/day proteinuria , respectively . When similarly stratified by proteinuria , mean systolic blood pressures were 141.4+/-23.5 and 140.9+/-20.3 mmHg , and mean diastolic blood pressures were 78.4+/-14.0 and 77.9+/-11.4 mmHg , respectively . Blood pressure control , according to published guidelines , was achieved in 128 patients ( 42.1 % ) . A further 86 ( 28.3 % ) patients had their AHM increased . The remaining 90 ( 29.6 % ) did not have their AHM increased . Of these , 40 were labelled ' at target blood pressure ' ( mean MAP 100.5+/-5.4 mmHg ) , 19 ' office hypertension ' and 11 ' unfavourable risk/benefit ratios ' . There were 108/304 ( 35.5 % ) patients who were not taking ACEI or ARB ( angiotensin receptor antagonist ) : 34/108 ( 31 % ) had previous ACEI failure due to hyperkalaemia ( 21/108 , 19 % ) or acute renal failure ( 17/108 , 16 % ) , and 61/108 ( 55 % ) were felt ' unlikely to benefit ' ( categories not mutually exclusive ) . Miscommunication with the primary physician and medication costs were not identified as significant barriers to improved blood pressure control or ACEI use . CONCLUSIONS Approximately 40 % of CRI patients are achieving current blood pressure goals and 64 % are prescribed ACEI/ARB in tertiary care nephrology clinics . Although the use of these strategies may be increasing , there remains room for improvement . Physicians should remain aware of the need to use these proven strategies in patients with CRI BACKGROUND The implementation of national estimated glomerular filatration rate reporting and the inclusion of renal-specific indicators in a primary care pay for performance ( P4P ) system since April 2006 has promoted identification and better management of risk factors related to chronic kidney disease ( CKD ) . In the UK , the P4P framework is known as the Quality and Outcomes Framework ( QOF ) . One of the key targets for intervention in primary care was hypertension . It is clear that hypertension is a major predictor of development and progression of CKD ; thus , targeting better blood pressure control is likely to have a positive impact on outcomes in CKD . The aim of this study was to evaluate the effectiveness of renal indicators outlined in P4P on the management of hypertension in primary care . To estimate the cost implication s of the result ing changes in prescribing patterns of antihypertensive medication following introduction of such indicators . METHODS We performed a prospect i ve cohort study using a large primary care data base . This cohort was taken from a data base collated as part of a clinical decision support system used to assist the management of CKD in primary care . We investigated a total population of 90 250 individuals on general practitioner ( GP ) registers with a valid serum creatinine estimation in the 6-year study period . A total of 10 040 patients had confirmed stage 3 - 5 CKD in the 2 years pre-QOF and formed the study cohort . Patients were studied over three time periods , pre-QOF ( 1 April 2004 to 31 March 2006 ) , 2 years post-QOF ( 1 April 2006 to 31 March 2008 ) and finally the two subsequent years ( 1 April 2008 to 31 March 2010 ) . The mean systolic and diastolic blood pressures ( BP ) together with antihypertensive medication were analysed over the three time periods . Cost calculation was based on 2009 British National Formulary list prices for antihypertensives . RESULTS The mean age of the cohort at the start of the study period was 64.8 years , 55 % were female . In those patients with stage 3 - 5 CKD 83.9 % were hypertensive , defined by a pre-P4P BP of > 140/85 or currently taking antihypertensive medication . The proportion of patients with CKD 3 - 5 attaining the BP target of 145/80 increased from 41.5 % in the pre-QOF period to 50.0 % in the post-QOF period . This increase was even more marked for those with hypertension in the pre-QOF period ( 28.8 - 45.1 % ) . In the hypertensive patients , mean BP fell from 146/ 
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CONCLUSIONS Based on this review , sufficiently vali date d QIs can be selected for measuring the quality of CKD care .