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Jhamb M, Weltman MR, Devaraj SM, Lavenburg LMU, Han Z, Alghwiri AA, Fischer GS, Rollman BL, Nolin TD, Yabes JG. Electronic Health Record Population Health Management for Chronic Kidney Disease Care: A Cluster Randomized Clinical Trial. JAMA Intern Med 2024; 184:737-747. [PMID: 38619824 PMCID: PMC11019443 DOI: 10.1001/jamainternmed.2024.0708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 02/12/2024] [Indexed: 04/16/2024]
Abstract
Importance Large gaps in clinical care in patients with chronic kidney disease (CKD) lead to poor outcomes. Objective To compare the effectiveness of an electronic health record-based population health management intervention vs usual care for reducing CKD progression and improving evidence-based care in high-risk CKD. Design, Setting, and Participants The Kidney Coordinated Health Management Partnership (Kidney CHAMP) was a pragmatic cluster randomized clinical trial conducted between May 2019 and July 2022 in 101 primary care practices in Western Pennsylvania. It included patients aged 18 to 85 years with an estimated glomerular filtration rate (eGFR) of less than 60 mL/min/1.73m2 with high risk of CKD progression and no outpatient nephrology encounter within the previous 12 months. Interventions Multifaceted intervention for CKD comanagement with primary care clinicians included a nephrology electronic consultation, pharmacist-led medication management, and CKD education for patients. The usual care group received CKD care from primary care clinicians as usual. Main Outcomes and Measures The primary outcome was time to 40% or greater reduction in eGFR or end-stage kidney disease. Results Among 1596 patients (754 intervention [47.2%]; 842 control [52.8%]) with a mean (SD) age of 74 (9) years, 928 (58%) were female, 127 (8%) were Black, 9 (0.6%) were Hispanic, and the mean (SD) estimated glomerular filtration rate was 36.8 (7.9) mL/min/1.73m2. Over a median follow-up of 17.0 months, there was no significant difference in rate of primary outcome between the 2 arms (adjusted hazard ratio, 0.96; 95% CI, 0.67-1.38; P = .82). Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker exposure was more frequent in intervention arm compared with the control group (rate ratio, 1.21; 95% CI, 1.02-1.43). There was no difference in the secondary outcomes of hypertension control and exposure to unsafe medications or adverse events between the arms. Several COVID-19-related issues contributed to null findings in the study. Conclusion and Relevance In this study, among patients with moderate-risk to high-risk CKD, a multifaceted electronic health record-based population health management intervention resulted in more exposure days to angiotensin-converting enzyme inhibitors/angiotensin receptor blockers but did not reduce risk of CKD progression or hypertension control vs usual care. Trial Registration ClinicalTrials.gov Identifier: NCT03832595.
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Affiliation(s)
- Manisha Jhamb
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Melanie R. Weltman
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Susan M. Devaraj
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Linda-Marie Ustaris Lavenburg
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Zhuoheng Han
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Alaa A. Alghwiri
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Gary S. Fischer
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Bruce L. Rollman
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Center for Behavioral Health, Media, and Technology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Thomas D. Nolin
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Jonathan G. Yabes
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Center for Research on Heath Care, Division of General Internal Medicine, Department of Medicine and Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
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Gallagher H, Methven S, Casula A, Rayner H, Lenguerrand E, Thomas N, Dawnay A, Kennedy D, Woolnough L, Nation M, Caskey FJ. A stepped wedge cluster randomized trial of graphical surveillance of kidney function data to reduce late presentation for kidney replacement therapy. Kidney Int 2024:S0085-2538(24)00339-9. [PMID: 38797327 DOI: 10.1016/j.kint.2024.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 04/07/2024] [Accepted: 04/30/2024] [Indexed: 05/29/2024]
Abstract
Late presentation for kidney replacement therapy (KRT) is an important cause of avoidable morbidity and mortality. Here, we evaluated the effect of a complex intervention of graphical estimated glomerular filtration rate (eGFR) surveillance across 15% of the United Kingdom population on the rate of late presentation using data routinely collected by the United Kingdom Renal Registry. A stepped wedge cluster randomized trial was established across 19 sites with eGFR graphs generated from all routine blood tests (community and hospital) across the population served by each site. Graphs were reviewed by trained laboratory or clinical staff and high-risk graphs reported to family doctors. Due to delays outside the control of clinicians and researchers few laboratories activated the intervention in their randomly assigned time period, so the trial was converted to a quasi-experimental design. We studied 6,100 kidney failure events at 20 laboratories served by 17 main kidney units. A total of 63,981 graphs were sent out. After adjustment for calendar time there was no significant reduction in the rate of presentation during the intervention period. Therefore, implementation of eGFR graph surveillance did not reduce the rate of late presentation for KRT after adjustment for secular trends. Thus, graphical surveillance is an intervention aimed at reducing late presentation, but more evidence is required before adoption of this strategy can be recommended.
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Affiliation(s)
- Hugh Gallagher
- SW Thames Renal Unit, Epsom and St Helier National Health Service Trust, Carshalton, Surrey, UK.
| | - Shona Methven
- Renal Unit, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, UK
| | - Anna Casula
- UK Renal Registry, Brandon House, Bristol, UK
| | - Hugh Rayner
- Retired Consultant Nephrologist, Birmingham, UK
| | - Erik Lenguerrand
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Nicola Thomas
- Institute of Health and Social Care, London South Bank University, London, UK
| | - Anne Dawnay
- Clinical Biochemistry, Barts Health National Health Service Trust, The Royal Hospital, London, UK
| | - David Kennedy
- Gateshead Health National Health Service Foundation Trust, QE Hospital, Tyne and Wear, UK
| | | | - Michael Nation
- Kidney Research UK, Stuart House, Peterborough, Cambridgeshire, UK
| | - Fergus J Caskey
- Population Health Science, Bristol Medical School, University of Bristol, Bristol, UK
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Mutatiri C, Ratsch A, McGrail M, Venuthurupalli SK, Chennakesavan SK. Primary and specialist care interaction and referral patterns for individuals with chronic kidney disease: a narrative review. BMC Nephrol 2024; 25:149. [PMID: 38689219 PMCID: PMC11061991 DOI: 10.1186/s12882-024-03585-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 04/23/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Timely referral of individuals with chronic kidney disease from primary care to secondary care is evidenced to improve patient outcomes, especially for those whose disease progresses to kidney failure requiring kidney replacement therapy. A shortage of specialist nephrology services plus no consistent criteria for referral and reporting leads to referral pattern variability in the management of individuals with chronic kidney disease. OBJECTIVE The objective of this review was to explore the referral patterns of individuals with chronic kidney disease from primary care to specialist nephrology services. It focused on the primary-specialist care interface, optimal timing of referral to nephrology services, adequacy of preparation for kidney replacement therapy, and the role of clinical criteria vs. risk-based prediction tools in guiding the referral process. METHODS A narrative review was utilised to summarise the literature, with the intent of providing a broad-based understanding of the referral patterns for patients with chronic kidney disease in order to guide clinical practice decisions. The review identified original English language qualitative, quantitative, or mixed methods publications as well as systematic reviews and meta-analyses available in PubMed and Google Scholar from their inception to 24 March 2023. RESULTS Thirteen papers met the criteria for detailed review. We grouped the findings into three main themes: (1) Outcomes of the timing of referral to nephrology services, (2) Adequacy of preparation for kidney replacement therapy, and (3) Comparison of clinical criteria vs. risk-based prediction tools. The review demonstrated that regardless of the time frame used to define early vs. late referral in relation to the start of kidney replacement therapy, better outcomes are evidenced in patients referred early. CONCLUSIONS This review informs the patterns and timing of referral for pre-dialysis specialist care to mitigate adverse outcomes for individuals with chronic kidney disease requiring dialysis. Enhancing current risk prediction equations will enable primary care clinicians to accurately predict the risk of clinically important outcomes and provide much-needed guidance on the timing of referral between primary care and specialist nephrology services.
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Affiliation(s)
- Clyson Mutatiri
- Renal Medicine, Wide Bay Hospital and Health Service, Bundaberg, QLD, Australia.
- Rural Clinical School, Faculty of Medicine, The University of Queensland, Bundaberg, QLD, Australia.
| | - Angela Ratsch
- Research Services, Wide Bay Hospital and Health Service, Hervey Bay, QLD, Australia
- Rural Clinical School, Faculty of Medicine, The University of Queensland, Hervey Bay, QLD, Australia
| | - Matthew McGrail
- Rural Clinical School, Faculty of Medicine, The University of Queensland, Rockhampton, QLD, Australia
| | - Sree Krishna Venuthurupalli
- Kidney Service, Department of Medicine, West Moreton Hospital and Health Service, Ipswich, QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
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Oliva-Damaso N, Delanaye P, Oliva-Damaso E, Payan J, Glassock RJ. Risk-based versus GFR threshold criteria for nephrology referral in chronic kidney disease. Clin Kidney J 2022; 15:1996-2005. [PMID: 36325015 PMCID: PMC9613424 DOI: 10.1093/ckj/sfac104] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Indexed: 02/22/2024] Open
Abstract
Chronic kidney disease (CKD) and kidney failure are global health problems associated with morbidity, mortality and healthcare costs, with unequal access to kidney replacement therapy between countries. The diversity of guidelines concerning referral from primary care to a specialist nephrologist determines different outcomes around the world among patients with CKD where several guidelines recommend referral when the glomerular filtration rate (GFR) is <30 mL/min/1.73 m2 regardless of age. Additionally, fixed non-age-adapted diagnostic criteria for CKD that do not distinguish correctly between normal kidney senescence and true kidney disease can lead to overdiagnosis of CKD in the elderly and underdiagnosis of CKD in young patients and contributes to the unfair referral of CKD patients to a kidney specialist. Non-age-adapted recommendations contribute to unnecessary referral in the very elderly with a mild disease where the risk of death consistently exceeds the risk of progression to kidney failure and ignore the possibility of effective interventions of a young patient with long life expectancy. The opportunity of mitigating CKD progression and cardiovascular complications in young patients with early stages of CKD is a task entrusted to primary care providers who are possibly unable to optimally accomplish guideline-directed medical therapy for this purpose. The shortage in the nephrology workforce has classically led to focused referral on advanced CKD stages preparing for kidney replacement, but the need for hasty referral to a nephrologist because of the urgent requirement for kidney replacement therapy in advanced CKD is still observed and changes are required to move toward reducing the kidney failure burden. The Kidney Failure Risk Equation (KFRE) is a novel tool that can guide wiser nephrology referrals and impact patients.
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Affiliation(s)
- Nestor Oliva-Damaso
- Department of Medicine, Division of Nephrology, Hospital Costa del Sol, Marbella, Malaga, Spain
| | - Pierre Delanaye
- Department of Nephrology-Dialysis-Transplantation, University of Liege, Centre Hospitalier Universitaire Sart Tilman, ULgCHU, Liege, Belgium
- Department of Nephrology-Dialysis-Apheresis, Hôpital Universitaire Carémeau, Nîmes, France
| | - Elena Oliva-Damaso
- Department of Medicine, Division of Nephrology, Hospital Universitario Doctor Negrin, Las Palmas de Gran Canaria, Spain
| | - Juan Payan
- Department of Medicine, Division of Nephrology, Hospital Costa del Sol, Marbella, Malaga, Spain
| | - Richard J Glassock
- Department of Medicine, Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Claudel SE, Schmidt IM, Verma A. A Call for Implementation Science: Achieving Equitable Access to SGLT2 Inhibitors. KIDNEY360 2022; 3:942-944. [PMID: 36128478 PMCID: PMC9438421 DOI: 10.34067/kid.0001512022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 02/25/2022] [Indexed: 01/10/2023]
Affiliation(s)
- Sophie E Claudel
- Department of Internal Medicine, Boston Medical Center, Boston, Massachusetts
| | - Insa M Schmidt
- Section of Nephrology, Department of Internal Medicine, Boston Medical Center, Boston, Massachusetts
| | - Ashish Verma
- Section of Nephrology, Department of Internal Medicine, Boston Medical Center, Boston, Massachusetts
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