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The American Journal of Managed Care April 2018
Delivering on the Value Proposition of Precision Medicine: The View From Healthcare Payers
Jane Null Kogan, PhD; Philip Empey, PharmD, PhD; Justin Kanter, MA; Donna J. Keyser, PhD, MBA; and William H. Shrank, MD, MSHS
Care Coordination for Children With Special Needs in Medicaid: Lessons From Medicare
Kate A. Stewart, PhD, MS; Katharine W.V. Bradley, PhD, MBA; Joseph S. Zickafoose, MD, MS; Rachel Hildrich, BS; Henry T. Ireys, PhD; and Randall S. Brown, PhD
Cost Sharing and Branded Antidepressant Initiation Among Patients Treated With Generics
Jason D. Buxbaum, MHSA; Michael E. Chernew, PhD; Machaon Bonafede, PhD; Anna Vlahiotis, MA; Deborah Walter, MPA; Lisa Mucha, PhD; and A. Mark Fendrick, MD
The Well-Being of Long-Term Cancer Survivors
Jeffrey Sullivan, MS; Julia Thornton Snider, PhD; Emma van Eijndhoven, MS, MA; Tony Okoro, PharmD, MPH; Katharine Batt, MD, MSc; and Thomas DeLeire, PhD
A Payer–Provider Partnership for Integrated Care of Patients Receiving Dialysis
Justin Kindy, FSA, MAAA; David Roer, MD; Robert Wanovich, PharmD; and Stephen McMurray, MD
Financial Burden of Healthcare Utilization in Consumer-Directed Health Plans
Xinke Zhang, PhD; Erin Trish, PhD; and Neeraj Sood, PhD
Progress of Diabetes Severity Associated With Severe Hypoglycemia in Taiwan
Edy Kornelius, MD; Yi-Sun Yang, MD; Shih-Chang Lo, MD; Chiung-Huei Peng, DDS, PhD; Yung-Rung Lai, PharmD; Jeng-Yuan Chiou, PhD; and Chien-Ning Huang, MD, PhD
Currently Reading
Physician and Patient Tools to Improve Chronic Kidney Disease Care
Thomas D. Sequist, MD, MPH; Alison M. Holliday, MPH; E. John Orav, PhD; David W. Bates, MD, MSc; and Bradley M. Denker, MD
Provider and Patient Burdens of Obtaining Oral Anticancer Medications
Daniel M. Geynisman, MD; Caitlin R. Meeker, MPH; Jamie L. Doyle, MPH; Elizabeth A. Handorf, PhD; Marijo Bilusic, MD, PhD; Elizabeth R. Plimack, MD, MS; and Yu-Ning Wong, MD, MSCE

Physician and Patient Tools to Improve Chronic Kidney Disease Care

Thomas D. Sequist, MD, MPH; Alison M. Holliday, MPH; E. John Orav, PhD; David W. Bates, MD, MSc; and Bradley M. Denker, MD
Decision support tools, disease registries, and patient engagement materials can improve population-based chronic kidney disease care.

Objectives: To determine if electronic health record (EHR) tools and patient engagement can improve the quality of chronic kidney disease (CKD) care.

Study Design: Randomized controlled trial.

Methods: We enrolled 153 primary care physicians caring for 3947 high-risk and 3744 low-risk patients with stage III CKD across 13 ambulatory health centers in eastern Massachusetts. Intervention physicians received a set of electronic alerts during office visits recommending risk-appropriate CKD care. Patients of intervention physicians also received tailored educational mailings. For high-risk patients, we assessed for a visit with a nephrologist and prescription of an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) during the 12-month study period. For low-risk patients, we assessed for a urine microalbumin screening and prescription of an ACE inhibitor or ARB during the 12-month study period.

Results: Among high-risk patients, those in the intervention arm were significantly more likely to have an office visit with a nephrologist compared with those in the control arm (45% vs 34%; <.001). Among low-risk patients, those in the intervention arm were significantly more likely than those in the control arm to have received urine microalbumin testing (45% vs 21%; <.001). There was no difference between the intervention and control arms in rates of prescription of an ACE inhibitor or ARB in either the high-risk patient group (76% vs 79%; = .17) or the low-risk patient group (64% vs 65%; = .57).

Conclusions: A combined program of EHR tools and patient engagement improved some areas of CKD care, but substantial gaps remain.

Am J Manag Care. 2018;24(4):e107-e114
Takeaway Points

We randomized 153 primary care physicians caring for nearly 8000 patients with chronic kidney disease (CKD) to receive an intervention that combined electronic decision support tools, patient engagement materials, and collaboration between primary care and nephrology. 
  • Awareness of CKD is low among patients and physicians.
  • The intervention was favorably received by physicians and patients. 
  • We improved some measures of CKD care. 
  • We developed a practical population-based approach to assist accountable care organizations that are seeking to engage collaboration between primary care and specialty care to improve the quality of CKD care.
Chronic kidney disease (CKD) affects more than 25 million Americans, or more than 10% of the adult population.1 Effective management of moderate-stage CKD is needed to reduce the high mortality rates and extensive costs associated with progression to more advanced kidney failure.2-7

Many challenges exist to improving care for CKD,8,9 which remains a frequently unrecognized condition by both primary care physicians (PCPs)10-14 and their patients.1,15-17 Just 12% of patients with stage III or IV CKD are aware of their diagnosis, and just 63% of PCPs can correctly identify the presence of CKD.18 However, monitoring for disease progression, using appropriate medications, and involving nephrologists early can improve CKD outcomes.19

This highlights the need for healthcare systems to develop a systematic approach to treating this condition that supports primary care providers and nephrologists.7 Electronic health records (EHRs) present an opportunity to deliver appropriate care by identifying patients with CKD, stratifying the patient population, and facilitating tailored treatment and care coordination among patients, primary care, and nephrology.20 We conducted a randomized controlled trial to assess the impact of a comprehensive set of EHR tools and patient engagement materials to improve the management of CKD.


Study Design

This 18-month trial was conducted from 2011 to 2013, with patient enrollment occurring during the initial 6 months and all patients followed for 12 months after enrollment. We randomly assigned PCPs to receive alerts within the EHR during office visits for patients with CKD and mailed educational materials to patients of physicians in the intervention arm. The Human Studies Committee at Brigham and Women’s Hospital approved the study protocol, and a waiver of informed consent was approved for physicians and patients. The trial was registered at (ID NCT01203813).

Study Population
We conducted our study at Harvard Vanguard Medical Associates, an integrated multispecialty group practice in eastern Massachusetts caring for approximately 300,000 adult patients. The system has significant experience in population health management, such as participation as a Pioneer Accountable Care Organization. The practices use a common EHR (Epic Systems; Verona, Wisconsin) that captures clinical notes, electronic diagnosis codes, specialty referrals, medication prescriptions, and laboratory test results. This system has delivered automated reporting of estimated glomerular filtration rate (eGFR), computed using the Modification of Diet in Renal Disease (MDRD) Study equation. The EHR does not provide decision support for patients with CKD. Nephrology services are provided by 8 nephrologists employed by the group practice.

We enrolled 153 physicians across 13 health centers and 7691 patients aged 18 to 80 years with an established diagnosis of stage III CKD (Figure). The diagnosis was based on meeting each of the following criteria: 1) the presence of an office visit with a PCP within the group practice within the prior 18 months, 2) the presence of at least 2 eGFR results between 30 and 60mL/min/1.73m2 within the prior 5 years, 3) the qualifying abnormal eGFR results were separated by at least 90 days, and 4) the most recent eGFR was less than 60 mL/min/1.73m2.

Randomization and Interventions

The intervention was randomized at the individual physician level. Within each health center, we paired clinicians based on their number of eligible patients with CKD and then randomly assigned 1 physician in each pair to the intervention arm.

Based on local consensus and emerging data on the importance of both eGFR and albuminuria,21 we stratified patients with stage III CKD according to their risk of complications and identified relevant treatment targets. Our local consensus was achieved prior to the publication of recent guidelines by the Kidney Disease: Improving Global Outcomes (KDIGO) initiative7 and involved gathering input from both primary care and nephrology leadership within our multispecialty group practice using current data on predictors of mortality for patients with CKD. “High-risk” patients were defined as those with either 1) at least 1 eGFR of less than 45 mL/min/1.73m2 in the prior 5 years or 2) at least 1 eGFR of at least 45 mL/min/1.73m2 but less than 60 mL/min/1.73m2, in combination with the presence of diabetes or albuminuria (urine microalbumin >30 mcg/mg or spot protein to creatinine ratio >0.15 mcg/mg). All other patients—specifically, those with an eGFR of at least 45 mL/min/1.73m2 but less than 60 mL/min/1.73m2 and no history of diabetes or albuminuria—were considered “low-risk”. We identified our treatment targets using the same process, and for high-risk patients, we recommended use of an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB), as well as referral to a nephrologist. For low-risk patients, we recommended use of an ACE inhibitor or ARB, as well as annual monitoring of urine microalbumin to assess for disease progression and risk stratification.

All EHR alerts were displayed when physicians accessed the electronic ordering module of the patient chart. During office visits with high-risk patients, PCPs received up to 2 alerts. The first alert recommended a referral to a nephrologist if no such specialty office visit had occurred in the prior 12 months (eAppendix A [eAppendices available at]). The second alert recommended prescription of an ACE inhibitor or ARB if the patient carried a diagnosis of hypertension or albuminuria, had not been prescribed the medication in the last 12 months, and had no documented allergy to such medication. 

During office visits with low-risk patients, PCPs received up to 2 alerts. The first was the same ACE inhibitor alert used for high-risk patients. The second recommended overdue annual laboratory tests, including those for urine microalbumin, serum creatinine, low-density lipoprotein (LDL) cholesterol, 25-hydroxy (OH) vitamin D, parathyroid hormone, calcium, phosphorus, and hemoglobin.

Our intervention included a mailed outreach program to promote patient engagement. We encouraged PCPs in the intervention arm to enroll patients using 2 strategies. First, all electronic reminders also prompted physicians to enroll patients in the mailed outreach program (eAppendix B). Second, for those physicians who did not respond to the request to enroll a patient via the electronic alert, we sent a follow-up postcard within 1 month of the office visit requesting them to enroll the patient. We required physicians to enroll patients to ensure that patients received a diagnosis of CKD from their care team prior to receiving any mailings.

The outreach program consisted of quarterly mailings to patients that provided tailored treatment recommendations based on detailed extracts from their EHR. The mailings were based on educational materials developed by the National Kidney Disease Education Program (eAppendix C).22 These mailings provided recommendations specific to CKD for managing blood pressure, appropriate use of ACE inhibitors or ARBs, education on current medications, and recommendations for overdue laboratory tests or follow-ups on previously abnormal results.

Physicians in the control group received no EHR alerts, and their patients were not eligible to receive the mailed outreach program.

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