Abstract and Introduction
Abstract
Background: Early detection of chronic kidney disease (CKD) can lead to interventions to prevent renal failure and reduce risk for cardiovascular disease, yet adherence to treatment goals is suboptimal in the primary care setting. The purpose of this study was to assess whether clinical decision support (CDS) can be used to improve the identification and management of CKD.
Methods: This 2 year demonstration study was conducted in 11 primary care PPRNet practices. CDS included a risk assessment tool, health maintenance protocols, flow chart and a patient registry. Practices received performance reports and hosted annual half day on-site visits.
Results: There were statistically significant increases in screening for albuminuria (median 24 month change 30%, p < 0.0005) and monitoring albuminuria (median 24 month change 25%, p < 0.0005). An absolute 23.5% improvement in appropriate use of ACE-inhibitor or angiotensin receptor blocker and an absolute 7.0% improvement in hemoglobin measurement were not statistically significant. There were no clinical or statistically significant differences in other CKD CQMs. Facilitators to CDS use included practices' prioritization of improving CKD and staff use of standing orders. Barriers included incorporating use into existing workflow and variable use among providers.
Conclusions: Use of CDS to improve CKD identification and management in primary care practices shows promise. However, other barriers must be addressed to effectively achieve improvements in CKD outcomes.
Introduction
The prevalence of chronic kidney disease (CKD) is increasing in the United States.[1,2] In addition to being a risk factor for progression to end-stage renal disease, CKD is a risk factor for cardiovascular disease and all-cause mortality.[3,4] The majority of patients with CKD are managed solely by primary care physicians,[5,6] yet primary care adherence to clinical practice guidelines seems to be suboptimal.[7–9] Interventions to improve the early identification and management of patients with CKD could reduce risks for the progression of renal disease and cardiovascular disease and have a major impact on public health.[10]
Inadequate recognition of patients with CKD and lack of awareness of treatment guidelines are 2 major barriers to providing quality care to patients with CKD.[11] Electronic-health record (EHR)– based reminders and clinical decision support (CDS) have been identified as potential tools to improve the identification of CKD, facilitate monitoring, and improve adherence to treatment targets. To date, however, only a few small, single-site studies have evaluated the use of EHR-based tools to improve CKD care,[12,13] and none have assessed provider and staff perceptions of their use.[14,15]
This 2-year demonstration study was designed to assess the impact of EHR-based CDS tools on a set of primary care CKD clinical quality measures (CQMs). We previously published the consensus process used to develop these CQMs.[16] The purpose of this article is to present the impact of the intervention and describe facilitators and barriers to the use of the CDS tools.
J Am Board Fam Med. 2016;29(5):604-612. © 2016 American Board of Family Medicine
