A Risk Based Approach to Improving Management of Chronic Kidney Disease

Although primary care represents the front line in the early identification and management of chronic kidney disease (CKD), it is often unrecognized by primary care physicians (PCPs). Effective management of earlier stage CKD reduces mortality rates and the costs associated with progression to advanced kidney failure. Existing clinical practice guidelines promote monitoring for progressive kidney disease, as well as aggressive management of cardiovascular risk and the complications of metabolic bone disease and anemia. The overall goal of this study was to implement a program to improve the quality of CKD care using disease registries and decision support tools within an advanced electronic health record.

The specific aims of this project were to:

• Use computerized clinical information systems to identify baseline predictors of appropriate evaluation and treatment of Stages 3 and 4 chronic kidney disease, including patient characteristics and nephrology involvement.
• Assess whether quality of care for Stage 3 chronic kidney disease can be substantially improved over 18 months by: 1) point-of-care electronic alerts to primary care physicians recommending risk-appropriate care; and 2) quarterly mailings to patients providing self-management support materials, including tailored recommendations based on personalized data from an electronic disease registry.
• Assess the relationship between utilization of the intervention components and primary care physician attitudes toward both chronic kidney disease management and electronic reminder systems.

A randomized trial of 9,502 primary care patients with CKD cared for by 158 PCPs at a multispecialty integrated group practice was conducted. The PCPs were randomly assigned to receive a set of electronic alerts that recommended risk-appropriate care for patients with CKD. Physicians in the intervention group were also given the option to enroll patients in a self-management support program consisting of quarterly tailored mailings. Primary outcomes for the study included: 1) a visit to a nephrologist (high-risk patients); 2) initiation of an angiotensin converting enzyme (ACE) inhibitor (high and low risk patients); and 3) performance of annual urine protein screening (low-risk patients).

Intervention physicians enrolled 22 percent of their patients in the educational mailing program. High risk patients of intervention physicians were more likely to be evaluated by a nephrologist than were high-risk patients in the control group. This effect was particularly pronounced among patients who received the educational mailings and those with increasing numbers of primary care visits. Use of ACE inhibitors was not increased among either high- or low-risk patients, though use was increased among patients who received educational mailings. Low-risk patients of intervention physicians were more likely to receive annual urine protein screening than were patients of control physicians.

The researchers found that their program significantly improved quality of care for both high- and low-risk patients with CKD—increasing the collaborative care with nephrologists, improving disease monitoring through appropriate laboratory testing, and in some cases, increasing use of appropriate medications. The program was well received by PCPs and patients responded positively to the educational mailings.