Can EHR Tools Induce Improved Care of Patients With CKD?

October 26, 2020
Allison Inserro
Allison Inserro

Can a population health framework focused on a certain set of patients with chronic disease (ie, chronic kidney disease [CKD]) improve care in the primary care setting?

Most patients with chronic kidney disease (CKD), in the early stages at least, typically start out under the care of a primary care provider, who may have limited time and may not be up to date on the latest guidelines, particularly on newer FDA-approved therapies.

An abstract and a session at Kidney Week discussed the idea of using the population health framework as being laser-focused on a certain set of patients with chronic disease, in this case, CKD.

Khaled Abdel-Kader MD, MS, a nephrologist and assistant professor of medicine at Vanderbilt University, reviewed Kidney CHAMP, an ongoing study funded by the National Institutes of Health that seeks to use an electronic health record (EHR)–based population health management (PHM) approach to improve CKD care.

He and Manisha Jhamb, MD, MPH, at the University of Pittsburgh, are leading the study, along with pharmacists, a nurse, and a chief medical informatics specialist.

The hypothesis of the pragmatic, randomized controlled trial is to see if an EHR-based PHM will improve hypertension control, use of renin-angiotensin-aldosterone system (RAAS) inhibitors, and avoidance of renally contraindicated medications and delay CKD progression

The 42-month study is cluster randomized at the practice level and stratified by the number of high-risk CKD patients per practice; it ultimately seeks to enroll 1650 patients.

Thus far, there are 365 PCPs enrolled, about 65 of those are advanced practice providers.

Eligible patients are those aged 18 to 85 years who are not being followed by a nephrologist, with at least 2 visits to their PCP in the past 24 months and an estimated glomerular filtration rate (eGFR) ratio below 60 ml/min/1.732 m within 12 months.

The patients are considered “high-risk CKD” if 1 of 3 criteria are met:

  • CKD stage 4, with an eGFR of 15 to 29 ml/min/1.732
  • 5-year risk of end-stage renal disease defined by a validated kidney failure risk equation of 4% or greater
  • Flagged using an internally validated machine learning model that takes into account healthcare utilization, longitudinal change in serum creatine, and medication use.

Patients in the intervention arm receive a nephrologist-led electronic consult and pharmacist-led telephonic medication therapy management (MTM). The consult is done via the EHR for the PCP to review and order at the upcoming office visit. Medication recommendations included use of RAAS inhibitors, sodium-glucose cotransporter 2 (SGLT2) inhibitors, glucagon-like peptide 1 (GLP-1) receptor agonists, and statins.

In the first set of data from the study, collected from July 1, 2019, to January 31, 2020, 125 patients received an e-consult and 121 patients received MTM.

A total of 83 recommendations were provided to PCPs in the EHR, but their uptake varied.

For initiation or dose escalation of RAAS inhibitors, 41% (19 of 46) were ordered.

Two of 8 recommendations regarding GLP-1 receptor agonists were implemented (25%) and 2 of 24 recommendations for SGLT2 inhibitor initiation were implemented (8%).

Although 5 recommendations were made for statins, none were implemented, but baseline statin use was already higher than 75%.

Additional strategies are needed to improve the use of evidence-based recommendations, the study says.

Reference

Weltman MR, Chen H, Yabes J, et al Uptake of evidence-based recommendations to improve care for CKD patients in the kidney coordinated health management partnership (Kidney CHAMP) study. Presented at American Society of Nephrology Kidney Week. Abstract PO0579.