Use of Clinical Decision Support to Improve Primary Care Identification and Management of Chronic Kidney Disease (CKD)

Litvin, Cara B.; Hyer, J. Madison; Ornstein, Steven M.

doi:10.3122/jabfm.2016.05.160020

Cited by 44 publications

(52 citation statements)

References 21 publications

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“…The most commonly reported barrier within this domain was a fear of frightening patients by delivering a diagnosis of CKD. This was reported in 10 studies [6,7,9,10,22,24,26,32,33,35]. The source of fear for practitioners in primary care appeared to frequently be due to the perception that patients did not understand CKD and therefore would not be able to cope with the diagnosis.…”

Section: Beliefs About Consequencesmentioning

confidence: 91%

“…Of the 20 included studies, 12 were interviews [7,10,[22][23][24][25][26][27][28][29][30][31], six were focus groups [5,6,8,[32][33][34][35][36], and two were surveys with open-ended responses [9,37] (Table 1). General practitioners, nurses, practice managers, pharmacists and medical assistants were represented across the 20 studies.…”

Section: Characteristics Of Included Studiesmentioning

confidence: 99%

“…The most commonly reported barriers related to detection and management of CKD in primary care were categorised into the 'Environmental context and resources' domain and were reported in 16 studies [5,6,8,9,22,24,[26][27][28][29][30][31][32][33][34][35][36][37]. PC-Ps frequently perceived they lacked time to devote to this task [6,8,9,22,[26][27][28][29][30][31][32][33][34][35] and this was exacerbated by the limited amount of time available for patient appointments.…”

Section: Environmental Context and Resourcesmentioning

confidence: 99%

“…A lack of educational resources for patients [8,33,34,37] was reported, although minimal detail was provided on the type of resources (for example brochures, online materials) that were desired. In addition, technological issues such as software not automatically flagging abnormal results [24,28,29]; and a lack of renumeration for tasks such as CKD screening within health system rebates [9,22] were reported. Attempts to implement changes in the primary care setting were obstructed by variations in practice operations [22], as well as a lack of CKDspecific information in insurance reports and other performance data [28].…”

Section: Environmental Context and Resourcesmentioning

confidence: 99%

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Barriers and enablers to detection and management of chronic kidney disease in primary healthcare: a systematic review

2020

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Background: Chronic kidney disease (CKD) is growing population health concern worldwide, and with early identification and effective management, kidney disease progression can be slowed or prevented. Most patients with risk factors for chronic kidney disease are treated within primary healthcare. Therefore, it is important to understand how best to support primary care providers (PC-P) to detect and manage chronic kidney disease. The aim of this systematic review was to evaluate barriers and enablers to the diagnosis and management of CKD in primary care. Methods: A systematic review of qualitative research on the barriers and/or enablers to detection and/or management of CKD in adults within primary healthcare was conducted. The databases Medline (EBSCO), PubMed, Cochrane CENTRAL, CINAHL (EBSCO) and Joanna Briggs Institute Evidence Based Practice (Ovid) were searched until 27th August 2019. Barriers and/or enablers reported in each study were identified, classified into themes, and categorised according to the Theoretical Domains Framework. Results: A total of 20 studies were included in this review. The most commonly reported barriers related to detection and management of CKD in primary care were categorised into the 'Environmental context and resources' domain (n = 16 studies). Overall, the most common barrier identified was a lack of time (n = 13 studies), followed by a fear of delivering a diagnosis of CKD, and dissatisfaction with CKD guidelines (both n = 10 studies). Overall, the most common enabler identified was the presence of supportive technology to identify and manage CKD (n = 7 studies), followed by the presence of a collaborative relationship between members of the healthcare team (n = 5 studies). Conclusion: This systematic review identified a number of barriers and enablers which PC-P face when identifying and managing CKD. The findings of this review suggest a need for time-efficient strategies that promote collaboration between members of the healthcare team, and practice guidelines which consider the frequently comorbid nature of CKD. Enhanced collaboration between PC-P and nephrology services may also support PC-Ps when diagnosing CKD in primary care, and facilitate improved patient self-management.

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Section: Beliefs About Consequencesmentioning

confidence: 91%

Section: Characteristics Of Included Studiesmentioning

confidence: 99%

Section: Environmental Context and Resourcesmentioning

confidence: 99%

Section: Environmental Context and Resourcesmentioning

confidence: 99%

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Barriers and enablers to detection and management of chronic kidney disease in primary healthcare: a systematic review

2020

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“…Presence of albuminuria or proteinuria is associated with increased risk for cardiovascular and kidney disease[1, 2]. While guidelines recommend screening for kidney disease using urinalysis dipstick for patients with hypertension (and urine albumin/creatinine ratio [ACR] for those with diabetes or chronic kidney disease [CKD])[3, 4], screening remains suboptimal[5–8]. Top research priorities raised by patients with CKD include improving strategies of early kidney disease identification, which could allow implementation of interventions to slow progression of disease [9, 10].…”

Section: Introductionmentioning

confidence: 99%

Improving Proteinuria Screening with Mailed Smartphone Urinalysis Testing in Previously Unscreened Patients with Hypertension: a Randomized Controlled Trial

Leddy

Green

Yule

et al. 2019

Preprint

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BackgroundProteinuria screening is recommended for patients with hypertension to screen for kidney disease and identify those at elevated risk for cardiovascular disease. However, screening rates among hypertensive patients are low. Home testing strategies may be useful in improving proteinuria screening adherence.MethodsWe conducted an individual-level, randomized trial at 55 primary care clinic sites in the Geisinger Health System to evaluate the effectiveness of a strategy using home smartphone urinalysis test (Dip.io) to complete proteinuria screening in previously unscreened non-diabetic patient portal users with hypertension. All patients received an educational letter and a standing urinalysis lab order, and then were randomized to control (usual care) or intervention. Intervention arm participants were invited to complete proteinuria screening with a mailed home smartphone urinalysis test. Co-primary outcomes were completion of proteinuria screening and number of albuminuria cases (albumin/creatinine ratio [ACR] ≥ 30 mg/g or protein/creatinine ratio ≥ 150 mg/g) at the end of 3 months. We also evaluated patient satisfaction with the home test, and compliance with recommendations for patients with newly detected albuminuria.ResultsA total of 999 patients were randomized to intervention or control. Out of 499 patients assigned to the intervention arm, 253 were reached by phone, and 69/97 (71.1%) consented patients completed the home test. Overall, the intervention increased proteinuria screening completion (28.9% vs. 18.0%; p<0.001) with no effect on the number of albuminuria cases (4 vs. 4) although only 6/57 (10.5%) patients with trace or 1+ urine dipstick protein had a follow-up quantitative test. Among the 55 patients who completed a survey after the home test, 89% preferred testing at home rather than the physician’s office.ConclusionsA strategy using a home urinalysis smartphone test increased proteinuria screening rates in previously unscreened patients with hypertension and may be useful in increasing rates of proteinuria screening compliance. Future studies are needed to determine whether improving early detection of kidney disease can improve future kidney health.Trial RegistrationClinical Trial Registry: NCT03470701https://clinicaltrials.gov/ct2/show/NCT03470701

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Clinical Decision Support for Hypertension Management in Chronic Kidney Disease

Samal,

Kilgallon,

Lipsitz

et al. 2024

JAMA Intern Med

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ImportanceChronic kidney disease (CKD) affects 37 million adults in the United States, and for patients with CKD, hypertension is a key risk factor for adverse outcomes, such as kidney failure, cardiovascular events, and death.ObjectiveTo evaluate a computerized clinical decision support (CDS) system for the management of uncontrolled hypertension in patients with CKD.Design, Setting, and ParticipantsThis multiclinic, randomized clinical trial randomized primary care practitioners (PCPs) at a primary care network, including 15 hospital-based, ambulatory, and community health center–based clinics, through a stratified, matched-pair randomization approach February 2021 to February 2022. All adult patients with a visit to a PCP in the last 2 years were eligible and those with evidence of CKD and hypertension were included.InterventionThe intervention consisted of a CDS system based on behavioral economic principles and human-centered design methods that delivered tailored, evidence-based recommendations, including initiation or titration of renin-angiotensin-aldosterone system inhibitors. The patients in the control group received usual care from PCPs with the CDS system operating in silent mode.Main Outcomes and MeasuresThe primary outcome was the change in mean systolic blood pressure (SBP) between baseline and 180 days compared between groups. The primary analysis was a repeated measures linear mixed model, using SBP at baseline, 90 days, and 180 days in an intention-to-treat repeated measures model to account for missing data. Secondary outcomes included blood pressure (BP) control and outcomes such as percentage of patients who received an action that aligned with the CDS recommendations.ResultsThe study included 174 PCPs and 2026 patients (mean [SD] age, 75.3 [0.3] years; 1223 [60.4%] female; mean [SD] SBP at baseline, 154.0 [14.3] mm Hg), with 87 PCPs and 1029 patients randomized to the intervention and 87 PCPs and 997 patients randomized to usual care. Overall, 1714 patients (84.6%) were treated for hypertension at baseline. There were 1623 patients (80.1%) with an SBP measurement at 180 days. From the linear mixed model, there was a statistically significant difference in mean SBP change in the intervention group compared with the usual care group (change, −14.6 [95% CI, −13.1 to −16.0] mm Hg vs −11.7 [−10.2 to −13.1] mm Hg; P = .005). There was no difference in the percentage of patients who achieved BP control in the intervention group compared with the control group (50.4% [95% CI, 46.5% to 54.3%] vs 47.1% [95% CI, 43.3% to 51.0%]). More patients received an action aligned with the CDS recommendations in the intervention group than in the usual care group (49.9% [95% CI, 45.1% to 54.8%] vs 34.6% [95% CI, 29.8% to 39.4%]; P &lt; .001).Conclusions and RelevanceThese findings suggest that implementing this computerized CDS system could lead to improved management of uncontrolled hypertension and potentially improved clinical outcomes at the population level for patients with CKD.Trial RegistrationClinicalTrials.gov Identifier: NCT03679247

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Use of Clinical Decision Support to Improve Primary Care Identification and Management of Chronic Kidney Disease (CKD)

Cited by 44 publications

References 21 publications

Barriers and enablers to detection and management of chronic kidney disease in primary healthcare: a systematic review

Barriers and enablers to detection and management of chronic kidney disease in primary healthcare: a systematic review

Improving Proteinuria Screening with Mailed Smartphone Urinalysis Testing in Previously Unscreened Patients with Hypertension: a Randomized Controlled Trial

Clinical Decision Support for Hypertension Management in Chronic Kidney Disease

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