Clinical Decision Support Tools Improve Kidney Disease Diagnosis and Management

Clinical Decision Support Tools Improve Kidney Disease Diagnosis and Management

The use of clinical decision support tools shows promise in improving the identification and management of chronic kidney disease in primary care practices, a new study shows.

The study, “Use of Clinical Decision Support to Improve Primary Care Identification and Management of Chronic Kidney Disease (CKD),” published in the Journal of the American Board of Family Medicine, shows, however, that obstacles such as integrating these tools into the workflow of existing primary care practices still need to be addressed to achieve improvements in CKD outcomes.

“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,” Dr. Cara B. Litvin, MD, and her colleagues at the Medical University of South Carolina, wrote in the study, according to a news release.

The prevalence of chronic kidney disease, the progressive loss in kidney function over time, is increasing in the United States. CKD is a risk factor for end-stage renal disease, cardiovascular disease, and all-cause mortality. Early detection can lead to interventions to prevent renal failure and reduce risk for cardiovascular disease, yet adherence to treatment goals remains unsatisfactory in the primary care setting.

Clinical decision support (CDS) systems provide clinicians, healthcare staff, and patients with person-specific information that is intelligently filtered to improve healthcare. CDS encompasses a variety of tools to enhance decision-making in the clinical workflow, including computerized alerts and reminders to care providers and patients; clinical guidelines; and focused patient data reports and summaries.

“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 … [electronic health registry (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,” the authors wrote.

In the new study, Litvin and her colleagues developed several electronic health records-based CDS tools to improve the diagnosis and clinical management of CKD. These included an assessment tool to measure the risk of CKD, designed to be embedded into general or disease-specific progress notes; electronic health maintenance protocols, including prompts for eGFR (annual estimated glomerular filtrate rate), urine albumin, lipid and hemoglobin testing when due; a CKD patient registry; and EHR supported, designed to enable providers to concisely view CKD parameters over time.

A total of 12 primary care practices in 12 U.S. states, representing 25 doctors and 15 midlevel health providers, took part in the two-year study. All the primary care practices received performance reports, and the researchers conducted two half-day onsite visits per year to assess the “intervention”outcomes.

After 24 months, there were large statistically significant increases in screening for albuminuria for patients at risk for CKD (30 percent) and an increase of 25 percent was seen in albuminuria monitoring in patients with CKD, the researchers found. Albuminuria is a major prognostic indicator for cardiovascular disease, progression of disease, and death.

There was also an improvement of 23.5 percent in appropriate use of blood pressure lowering drugs (ACE-inhibitor or angiotensin receptor blocker) for patients with CKD. An improvement of 7 percent was seen in hemoglobin measurement for patients at risk for CKD. However, neither of these improvements were statistically significant, the researchers reported.

There were no statistically significant differences in any other clinical quality measures related to CKD.

Barriers observed during the intervention included incorporating CDS tools into existing workflow and variable use among providers, the researchers reported.

“… 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,” the authors 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,” they wrote.

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