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

Abstract

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.

Trends in using of antihypertensive medication among US CKD adults, NHANES 2001–2018

“…This may be caused by albuminuria undertesting, which leads to be under-recognized by clinician. A previous study in 2022 showed that only 9% of American veterans with hypertension who did not know CKD or diabetes had prior urine albumin/creatinine ratio measure ( 29 ). The proportion of ACEi/ARB treatment in CKD adults with ACR (30-300 mg/g) increased from 57.0% in 2001-2006 to 65.3% in 2007-2012, and remained stable thereafter.…”

Effects of a Knowledge-Translation Intervention on Early Dialysis Initiation: A Cluster Randomized Trial

“…In particular, studies targeting process outcomes such as measurement of albuminuria or prescription of renal angiotensin system inhibitors have been successful, whereas those targeting clinical outcomes such as CKD progression or hospitalizations have largely been negative. [22][23][24] Similarly, interventions such as audit and feedback and academic detailing have been effective, 14,25,26 whereas interventions that are primarily on the basis of decision support within the electronic health record have not. 27,28 With these features in mind, we designed our multifaceted intervention to include audit and feedback, academic detailing, and provided several visual aids to enhance the uptake of the intent-todefer strategy and decrease the proportion of patients who undergo early dialysis initiation.…”

The Effectiveness of Pharmacist Interventions in the Management of Patient with Renal Failure: A Systematic Review and Meta-Analysis

“… Forest plot of comparison: pharmacist contribution to comprehensive intervention vs. usual care for continuous and dichotomous data concerning clinical outcomes [ 12 , 13 , 14 , 15 , 17 , 18 , 19 , 20 , 21 , 22 , 24 , 27 , 28 , 29 , 36 , 37 ]. Differential change from baseline in SBP ( a ) and DBP ( b ); patients with an achieved BP goal ( c ); differential change from baseline in eGFR ( d ); #—adjusted for sex, baseline systolic BP, smoking status, body-mass index, and cluster characteristics (mean pharmacist year since graduation); ##—adjusted for the clinical variable at baseline (eGFR), interaction between study group and clinical variable at baseline, and patient’s age, sex, highest level of education, and eGFR, as well as pharmacist being an associate clinician and receiving remuneration for pharmaceutical opinions; BP goal was defined as <140/90 mmHg, except for: &—140/90 mmHg for non-proteinuric CKD and <130/80 for proteinuric CKD; ^—<140/90 mmHg for non-hypertensive patients, and <130/80 mmHg for hypertensive patients; $—<140/90 mmHg for subjects with neither condition, and <130/80 mmHg for DM/CKD patients *—<130/80 mmHg; months of follow-up were shown in brackets.…”