Improving Care for Patients With or at Risk for Chronic Kidney Disease Using Electronic Medical Record Interventions: A Pragmatic Cluster-Randomized Trial Protocol

Nash, Danielle M.; Ivers, Noah; Young, Jacqueline; Jaakkimainen, R. Liisa; Garg, Amit X.; Tu, Karen

doi:10.1177/2054358117699833

Cited by 8 publications

(5 citation statements)

References 50 publications

(70 reference statements)

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“…In this report, we describe the rationale, design, and initial implementation outcomes of a 3-arm pragmatic trial that assessed the feasibility and preliminary effectiveness of an eCDSS to improve CKD management in primary care compared with usual care. This study builds on previous pragmatic trials focused on EHR-based interventions to improve CKD management [28,29,51,52] and supports the feasibility of using EHRs to identify study participants, intervene in early CKD management, and measure study outcomes. Given its design as a pragmatic trial (per Pragmatic Explanatory Continuum Indicator Summary, or PRECIS, criteria [53]), we found high rates of participation by providers and low opt-out rates by patients.…”

Section: Discussionmentioning

confidence: 53%

A Pragmatic Cluster Randomized Trial of an Electronic Clinical Decision Support System to Improve Chronic Kidney Disease Management in Primary Care: Design, Rationale, and Implementation Experience

Khoong¹,

Karliner²,

Lo³

et al. 2019

JMIR Res Protoc

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Background The diagnosis of chronic kidney disease (CKD) is based on laboratory results easily extracted from electronic health records; therefore, CKD identification and management is an ideal area for targeted electronic decision support efforts. Early CKD management frequently occurs in primary care settings where primary care providers (PCPs) may not implement all the best practices to prevent CKD-related complications. Few previous studies have employed randomized trials to assess a CKD electronic clinical decision support system (eCDSS) that provided recommendations to PCPs tailored to each patient based on laboratory results. Objective The aim of this study was to report the trial design and implementation experience of a CKD eCDSS in primary care. Methods This was a 3-arm pragmatic cluster-randomized trial at an academic general internal medicine practice. Eligible patients had 2 previous estimated-glomerular-filtration-rates by serum creatinine (eGFR Cr ) <60 mL/min/1.73m 2 at least 90 days apart. Randomization occurred at the PCP level. For patients of PCPs in either of the 2 intervention arms, the research team ordered triple-marker testing (serum creatinine, serum cystatin-c, and urine albumin-creatinine-ratio) at the beginning of the study period, to be completed when acquiring labs for regular clinical care. The eCDSS launched for PCPs and patients in the intervention arms during a regular PCP visit subsequent to completing the triple-marker testing. The eCDSS delivered individualized guidance on cardiovascular risk-reduction, potassium and proteinuria management, and patient education. Patients in the eCDSS+ arm also received a pharmacist phone call to reinforce CKD-related education. The primary clinical outcome is blood pressure change from baseline at 6 months after the end of the trial, and the main secondary outcome is provider awareness of CKD diagnosis. We also collected process, patient-centered, and implementation outcomes. Results A multidisciplinary team (primary care internist, nephrologists, pharmacist, and informaticist) designed the eCDSS to integrate into the current clinical workflow. All 81 PCPs contacted agreed to participate and were randomized. Of 995 patients initially eligible by eGFR Cr , 413 were excluded per protocol and 58 opted out or withdrew, resulting in 524 patient participants (188 usual care; 165 eCDSS; and 171 eCDSS+). During the 12-month intervention period, 53.0% (178/336) of intervention patient participants completed triple-marker labs. Among these, 138/178 (77.5%) had a PCP appointment after the triple-marker labs resulted; the eCDSS was opened for 73.9% (102/138), with orders or education signed for 81.4% (83/102). Conclusions Successful integration of an eCDSS into primary care workflows and high eCDSS utilization rates at eligible visits suggest ...

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Section: Discussionmentioning

confidence: 53%

A Pragmatic Cluster Randomized Trial of an Electronic Clinical Decision Support System to Improve Chronic Kidney Disease Management in Primary Care: Design, Rationale, and Implementation Experience

Khoong¹,

Karliner²,

Lo³

et al. 2019

JMIR Res Protoc

View full text Add to dashboard Cite

show abstract

“…18 Outside of the United States, digital tools, including electronic registries, have been increasingly used to enhance CKD care in primary care settings. 19,20 In contrast, because population-based approaches to CKD care have only recently gained widespread traction in the United States, there has been little evidence to guide their implementation in US health care settings. In this issue of AJKD, Tuot et al 21 begin to fill this evidence gap.…”

Section: Ebony Boulwarementioning

confidence: 99%

Improving Primary Care for Patients With CKD in the Digital Era

Boulware

2018

American Journal of Kidney Diseases

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“…The widespread use of electronic health records has garnered great excitement about evaluating interventions that capitalize on technology to improve clinical care. In nephrology, we have limited experience with pragmatic randomized trials that have tested the potential of the electronic health record to improve management of persons at early stages of CKD (8)(9)(10)(11)(12)(13). Even fewer report lessons learned in the process of implementation (14).…”

Section: Introductionmentioning

confidence: 99%

Screening for CKD To Improve Processes of Care among Nondiabetic Veterans with Hypertension

Peralta

Frigaard

Rolón³

et al. 2020

CJASN

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Background and objectivesWe conducted a pilot, pragmatic, cluster-randomized trial to evaluate feasibility and preliminary effectiveness of screening for CKD using a triple-marker approach (creatinine, cystatin C, and albumin/creatinine ratio), followed by education and guidance, to improve care of hypertensive veterans in primary care. We used the electronic health record for identification, enrollment, intervention delivery, and outcome ascertainment.Design, setting, participants, & measurementsWe randomized 1819 veterans without diabetes but with hypertension (41 clusters) into three arms: (1) CKD screening followed by patient and provider education; (2) screening, education, plus pharmacist comanagement; or (3) usual care. The primary clinical outcome was BP change over 1 year. Implementation and process measures included proportion screened; CKD detection rate; and total and new use of renin-angiotensin system inhibitors, nonsteroidal anti-inflammatory drugs, and diuretics.ResultsMedian age was 68 years, 55% were white, 1658 (91%) had a prior creatinine measure, but only 172 (9%) had prior urine albumin/creatinine ratio, and 83 (5%) had a prior cystatin C measure. Among those in the intervention, 527 of 1215 (43%) were identified with upcoming appointments to have CKD screening. Of these, 367 (69%) completed testing. Among those tested, 77 (21%) persons had newly diagnosed CKD. After 1 year, change in systolic BP was −1 mm Hg (interquartile range, −11 to 11) in usual care, −2 mm Hg (−11 to 11) in the screen-educate arm, and −2 mm Hg (−13 to 10) in the screen-educate plus pharmacist arm; P=0.49. There were no significant differences in secondary outcomes in intention-to-treat analyses. In as-treated analyses, higher proportions of participants in the intervention arms initiated a renin-angiotensin system inhibitor (15% and 12% versus 7% in usual care, P=0.01) or diuretic (9% and 12% versus 4%, P=0.03).ConclusionsThe pragmatic design made identification, enrollment, and intervention delivery highly efficient. The limited ability to identify appointments resulted in inadequate between-arm differences in CKD testing rates to determine whether screening improves clinical outcomes.

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Improving Care for Patients With or at Risk for Chronic Kidney Disease Using Electronic Medical Record Interventions: A Pragmatic Cluster-Randomized Trial Protocol

Cited by 8 publications

References 50 publications

A Pragmatic Cluster Randomized Trial of an Electronic Clinical Decision Support System to Improve Chronic Kidney Disease Management in Primary Care: Design, Rationale, and Implementation Experience

A Pragmatic Cluster Randomized Trial of an Electronic Clinical Decision Support System to Improve Chronic Kidney Disease Management in Primary Care: Design, Rationale, and Implementation Experience

Improving Primary Care for Patients With CKD in the Digital Era

Screening for CKD To Improve Processes of Care among Nondiabetic Veterans with Hypertension

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