Original Investigation
Pathogenesis and Treatment of Kidney Disease
Automated Clinical Reminders for Primary Care Providers in the Care of CKD: A Small Cluster-Randomized Controlled Trial

https://doi.org/10.1053/j.ajkd.2011.08.028Get rights and content

Background

Primary care physicians (PCPs) care for most non–dialysis-dependent patients with chronic kidney disease (CKD). Studies suggest that PCPs may deliver suboptimal CKD care. One means to improve PCP treatment of CKD is clinical decision support systems (CDSSs).

Study Design

Cluster-randomized controlled trial.

Setting & Participants

30 PCPs in a university-based outpatient general internal medicine practice and their 248 patients with moderate to advanced CKD who had not been referred to a nephrologist.

Intervention

2 CKD educational sessions were held for PCPs in both arms. The 15 intervention-arm PCPs also received real-time automated electronic medical record alerts for patients with estimated glomerular filtration rates <45 mL/min/1.73 m2 recommending renal referral and urine albumin quantification if not done within the prior year.

Outcomes

Primary outcome was referral to a nephrologist; secondary outcomes were albuminuria/proteinuria assessment, CKD documentation, optimal blood pressure (ie, <130/80 mm Hg), and use of renoprotective medications.

Results

The intervention and control arms did not differ in renal referrals (9.7% vs 16.5%, respectively; between-group difference, −6.8%; 95% CI, −15.5% to 1.8%; P = 0.1) or proteinuria assessments (39.3% vs 30.1%, respectively; between-group difference, 9.2%; 95% CI, −2.7% to 21.1%; P = 0.1). For intervention and control patients without a baseline proteinuria assessment, 27.7% versus 16.3%, respectively, had one at follow-up (P = 0.06). After controlling for clustering, these findings were largely unchanged and no significant differences were apparent between groups.

Limitations

Small single-center university-based practice, use of a passive CDSS that required PCPs to trigger the electronic order set.

Conclusions

PCPs were willing to partake in a randomized trial of a CDSS to improve outpatient CKD care. Although CDSSs may have potential, larger studies are needed to further explore how best to deploy them to enhance CKD care.

Section snippets

Setting and Participants

The study was conducted at a large academic hospital-based general internal medicine (GIM) clinic where more than 11,000 patients are cared for annually. We approached GIM faculty at regularly scheduled department meetings. Physician faculty members who were not present during those meetings were contacted by telephone or e-mail. Faculty were eligible for study enrollment if they had at least a half-day GIM continuity clinic per week. Faculty without a continuity clinic or who were planning to

Baseline Characteristics

We screened 46 GIM faculty members (Fig 2). Fifteen were excluded due to lack of continuity clinics (N = 11) or pending departure (N = 4). Of 31 eligible physicians, 30 consented to the study and 15 were randomly assigned to the CDSS alert arm. There were no physician dropouts during the study. Provider characteristics in each arm were well matched at baseline (Table 1). Eligible patients in each arm were similar in sociodemographics and comorbid conditions at baseline (Table 1). However, a

Discussion

In this study, the overwhelming majority of PCPs at an outpatient GIM clinic were willing to participate in a randomized pilot trial assessing an automated clinical alert targeting patients with eGFR <45 mL/min/1.73 m2 for renal referrals and albuminuria/proteinuria assessments. Although the intervention did not increase renal referrals, it may have improved proteinuria assessments in patients who lacked one at baseline. A trend toward improved blood pressure control in patients with suboptimal

Acknowledgements

Support: This work was supported by an NKF Foundation Clinical Research Fellowship, Ruth L. Kirschstein National Research Service Award Institutional Research Training Grants T32-DK061296 and Individual Postdoctoral Training Grant F32-DK084676, and by National Institutes of Health (NIH) Grant K23DK090304 (Dr Abdel-Kader); however, the study design, data collection, analysis, interpretation, and manuscript preparation and submission were determined by the authors alone. This publication was also

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    Originally published online October 10, 2011.

    Trial registration: www.ClinicalTrials.gov; study number: NCT00688285.

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