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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
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Progress of Diabetes Severity Associated With Severe Hypoglycemia in Taiwan
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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.
DISCUSSION

In a large randomized controlled trial of patients with stage III CKD, we demonstrated that a quality improvement program consisting of electronic decision support combined with mailed patient self-management support tools significantly improved quality of care, including use of nephrology referrals and laboratory testing. In particular, our intervention resulted in increased screening rates for urine microalbumin, identifying patients who warrant more aggressive management given the importance of microalbuminuria in predicting disease progression.

Our study findings demonstrated that a large population of patients with CKD can be effectively triaged, with care being shared between primary care and nephrology. Prior interventions to improve CKD care have involved small sample sizes, lacked a randomized  design, or showed only modest intervention effects. Southern California Kaiser Permanente implemented a large population-based program to improve CKD care but observed an increase in visits to nephrologists from 20% to just 24% over a 5-year period.23 Similarly, a study of electronic prompts recommending referral to a nephrologist for patients with eGFR of less than 45 found that the prompts did not impact referral patterns.24 A study of a paper-based CKD checklist found that it was associated with improvement in CKD care, although it involved only 4 PCPs within a single health center.25

Our study findings also highlighted the importance of patient engagement in the management of CKD. We found that a large proportion of patients responding to the survey had not been informed of their CKD, which is consistent with prior research.15 In our study, nephrology consultation was associated with increased patient awareness of their disease. This supports prior findings that accurate diagnosis, likely followed by messaging from a trusted physician, can increase patient awareness.26 The National Kidney Foundation and various federal agencies have also supported population-based programs to improve awareness of CKD, including detection and treatment.27,28 Our program builds on these efforts by combining a program to increase diagnosis and awareness with a set of EHR tools embedded within the workflows of a delivery system to support proactive CKD management.

We also found that nearly one-fifth of patients did not agree with being diagnosed with CKD at the conclusion of our intervention. This general finding is critical to understanding the foundation of development of CKD management programs: the need to first partner with patients in the diagnosis of kidney disease. Our post hoc analyses identified the patient mailings as being of substantial importance in the effectiveness of the intervention. Patients who received these mailings were more likely to achieve the study end points compared with control-arm patients, and the magnitude of these effects was larger than that observed for intervention-arm patients who did not receive the mailings.

We also need to focus on engaging primary care in the management of CKD. Although physicians endorsed strong support for our intervention, only half of physicians in the intervention arm felt comfortable establishing the diagnosis of CKD based on currently recommended criteria. However, our post hoc analyses highlight the importance of primary care, because patients with at least 1 visit to their PCPs were much more likely to receive higher-quality care.

Although we had significant success with this program, it is important to note that we did not impact prescribing of ACE inhibitors and ARBs among all patients. Our lack of intervention effect may have been due to the relatively high rates of prescribing ACE inhibitors and ARBs in both study arms. This suggests that physicians may not require additional intervention, given that there is less room to demonstrate improvement in prescribing. In addition, it may be that the remaining patients not treated with ACE inhibitors or ARBs were deemed at higher risk of the complications of such treatment, outweighing the estimated benefits.

Limitations

Our study has important limitations. We focused on a chronic condition in which the clinical recommendations are changing and remain under some debate,29,30 including recommendations around defining high-risk patients, which patients to refer to nephrologists, and the precise monitoring parameters for metabolic bone disease with parathyroid hormone and vitamin D testing. Our internal consensus guidelines did end up being slightly different from the published guidelines.

We used the MDRD equation to estimate GFR, which may tend to underestimate GFR and identify a lower-risk population. A recent analysis by the Kaiser Permanente system, which also employs Epic and the MDRD equation, found that use of the CKD Epidemiology Collaboration equation can identify a more targeted patient population that is at higher risk of long-term complications of CKD.31

We also did not have additional information on PCP characteristics, such as time in clinical practice, that may have played a role in our study outcomes. Our patient survey analyses were limited by the lack of information from patients in the control group, which was due to our desire to avoid surveying patients about a diagnosis they may not have received from their physician team. Future surveys should focus on alternative methods to assess the entire population and achieve higher response rates to ensure representative information. In addition, future interventions should focus on how to reach broader patient populations, including those with limited literacy.

Finally, we did not evaluate long-term outcomes, such as mortality or disease progression, as our intervention was just 12 months’ duration and such outcomes take years to present. We did attempt to apply widely used process measures of CKD care, but we recognize that there is active debate regarding which process measures have the best links to clinical outcomes.

CONCLUSIONS

We developed an innovative intervention combining electronic decision support and patient outreach that improved quality of care in some areas. Future work should explore how EHRs can be used to improve provider and patient decision making and further collaboration among patients, PCPs, and specialist physicians as part of a comprehensive effort to improve health outcomes and value.

Author Affiliations: Division of General Medicine and Primary Care, Brigham and Women’s Hospital (TDS, AMH, EJO, DWB), Boston, MA; Department of Health Care Policy, Harvard Medical School (TDS), Boston, MA; Partners HealthCare System (TDS, DWB), Boston, MA; Renal Division, Beth Israel Deaconess Medical Center (BMD), Boston, MA; Department of Health Policy and Management, Harvard School of Public Health (DWB), Boston, MA; Harvard Vanguard Medical Associates (BMD), Boston, MA.

Source of Funding: Agency for Healthcare Research and Quality (R18 HS018226).

Author Disclosures: Dr Bates reports board membership, consultancies or paid advisory boards, patents received, and royalties not related to this work. His financial interests have been reviewed by Brigham and Women’s Hospital and Partners HealthCare in accordance with their institutional policies. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. 

Authorship Information: Concept and design (TDS, DWB, BMD); acquisition of data (TDS, BMD); analysis and interpretation of data (TDS, AMH, EJO, DWB, BMD); drafting of the manuscript (TDS, AMH, EJO); critical revision of the manuscript for important intellectual content (TDS, AMH, EJO, DWB, BMD); statistical analysis (TDS, AMH, EJO); provision of patients or study materials (TDS); obtaining funding (TDS); and supervision (TDS). 

Address Correspondence to: Thomas D. Sequist, MD, MPH, Partners Healthcare System, 800 Boylston St, Boston, MA 02199. Email: tsequist@partners.org.
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