In the Journals

Clinical decision support improves diagnosis, management of chronic kidney disease

The use of EHR-based clinical decision support tools, including risk assessment, a patient registry and electronic health maintenance protocols, “showed promise” in improving the identification and management of chronic kidney disease in primary care, according to data published in the Journal of the American Board of Family Medicine.

However, the researchers added that multiple barriers, such as incorporating clinical decision support (CDS) tools into existing workflow and variable use among PCPs, need to be addressed before improvements in chronic kidney disease outcomes are seen.

“The majority of patients with [chronic kidney disease] are managed solely by [PCPs], yet primary care adherence to clinical practice guidelines seems to be suboptimal,” Cara B. Litvin, MD, of the Medical University of South Carolina, and colleagues wrote. “Interventions to improve the early identification and management of patients with [chronic kidney disease] could reduce risks for the progression of renal disease and cardiovascular disease and have a major impact on public health…. [EHR]-based reminders and [CDS] have been identified as potential tools to improve the identification of [chronic kidney disease], facilitate monitoring, and improve adherence to treatment targets.”

To determine if EHR-based CDS can improve the diagnosis and management of chronic kidney disease in primary care, the researchers conducted a demonstration study that included 12 practices in 12 states, representing 25 physicians and 15 midlevel providers, from September 2012 to September 2014. Participating practices were part of the Primary Care Practices Research Network.

CDS included a risk assessment tool, designed to be embedded into progress notes used by providers at the point of care; electronic health maintenance protocols, including prompts for eGFR, urine albumin, lipid and hemoglobin testing when due; a chronic kidney disease patient registry; and an EHR-backed chronic kidney disease flowchart, allowing providers to review relevant parameters and risk factors over time. Practices received performance reports, and researchers conducted half-day onsite visits.

The researchers reported statistically significant increases in screening for albuminuria, with a median 24-month change of 30% (P < .0005). Likewise, there was a significant increase in albuminuria monitoring, with a median 24-month change of 25% (P < .0005). However, an absolute 23.5% improvement in the appropriate use of ACE-inhibitor, or angiotensin receptor blocker, and an absolutely 7% improvement in hemoglobin measurement were not statistically significant, the researchers said. There were no statistically significant differences in any other clinical quality measures related to chronic kidney disease. CDS use facilitators included practices’ desire to improve chronic kidney disease care and the staff use of standing orders. Barriers included incorporating CDS tools into existing workflow and variable use among providers.

“… CDS tools show promise for improving the identification of patients with [chronic kidney disease] in a group of diverse, ‘real-world’ primary care practices, particularly when operationalized by clinical staff,” Litvin and colleagues wrote. “However, organizational, provider, patient, and technical factors beyond the CDS tools themselves may affect whether they can be effectively used to improve care. For example, achieving improvements in [chronic kidney disease] outcomes, such as blood pressure control likely requires an additional focus on improving care coordination between primary care physicians and nephrologists and encouraging patient activation.” – by Jason Laday

Disclosure: The researchers report no relevant financial disclosures.

The use of EHR-based clinical decision support tools, including risk assessment, a patient registry and electronic health maintenance protocols, “showed promise” in improving the identification and management of chronic kidney disease in primary care, according to data published in the Journal of the American Board of Family Medicine.

However, the researchers added that multiple barriers, such as incorporating clinical decision support (CDS) tools into existing workflow and variable use among PCPs, need to be addressed before improvements in chronic kidney disease outcomes are seen.

“The majority of patients with [chronic kidney disease] are managed solely by [PCPs], yet primary care adherence to clinical practice guidelines seems to be suboptimal,” Cara B. Litvin, MD, of the Medical University of South Carolina, and colleagues wrote. “Interventions to improve the early identification and management of patients with [chronic kidney disease] could reduce risks for the progression of renal disease and cardiovascular disease and have a major impact on public health…. [EHR]-based reminders and [CDS] have been identified as potential tools to improve the identification of [chronic kidney disease], facilitate monitoring, and improve adherence to treatment targets.”

To determine if EHR-based CDS can improve the diagnosis and management of chronic kidney disease in primary care, the researchers conducted a demonstration study that included 12 practices in 12 states, representing 25 physicians and 15 midlevel providers, from September 2012 to September 2014. Participating practices were part of the Primary Care Practices Research Network.

CDS included a risk assessment tool, designed to be embedded into progress notes used by providers at the point of care; electronic health maintenance protocols, including prompts for eGFR, urine albumin, lipid and hemoglobin testing when due; a chronic kidney disease patient registry; and an EHR-backed chronic kidney disease flowchart, allowing providers to review relevant parameters and risk factors over time. Practices received performance reports, and researchers conducted half-day onsite visits.

The researchers reported statistically significant increases in screening for albuminuria, with a median 24-month change of 30% (P < .0005). Likewise, there was a significant increase in albuminuria monitoring, with a median 24-month change of 25% (P < .0005). However, an absolute 23.5% improvement in the appropriate use of ACE-inhibitor, or angiotensin receptor blocker, and an absolutely 7% improvement in hemoglobin measurement were not statistically significant, the researchers said. There were no statistically significant differences in any other clinical quality measures related to chronic kidney disease. CDS use facilitators included practices’ desire to improve chronic kidney disease care and the staff use of standing orders. Barriers included incorporating CDS tools into existing workflow and variable use among providers.

“… CDS tools show promise for improving the identification of patients with [chronic kidney disease] in a group of diverse, ‘real-world’ primary care practices, particularly when operationalized by clinical staff,” Litvin and colleagues wrote. “However, organizational, provider, patient, and technical factors beyond the CDS tools themselves may affect whether they can be effectively used to improve care. For example, achieving improvements in [chronic kidney disease] outcomes, such as blood pressure control likely requires an additional focus on improving care coordination between primary care physicians and nephrologists and encouraging patient activation.” – by Jason Laday

Disclosure: The researchers report no relevant financial disclosures.