A CKD Clinical Decision Support System: A Cluster Randomized Clinical Trial in Primary Care Clinics

Abstract

Rationale & ObjectiveThe study aimed to develop, implement, and evaluate a clinical decision support (CDS) system for chronic kidney disease (CKD) in a primary care setting, with the goal of improving of CKD care in adults. Study DesignCluster randomized trial. Setting & Participants32 midwestern primary care clinics were randomly assigned to either receive usual care or CKD-CDS intervention. Between April 2019 and March 2020, we enrolled 6,420 patients aged 18-75 years with laboratory-defined GFR categories of CKD Stage G3 and G4, as well as one or more of six CKD care gaps: absence of a CKD diagnosis, suboptimal blood pressure (BP) or glycated hemoglobin (A1C) levels, indication for angiotensin converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) but not prescribed, a nonsteroidal anti-inflammatory agent (NSAID) on the active medication list, or an indicated nephrology referral. InterventionThe CKD-CDS provided personalized suggestions for CKD care improvement opportunities directed to both patients and clinicians at primary care encounters. OutcomesWe assessed the proportion of patients meeting each of 6 CKD-CDS quality metrics representing care gap resolution after18 months. ResultsThe adjusted proportions of patients meeting quality metrics in CKD-CDS versus usual care were as follows: CKD diagnosis documented (26.6% vs. 21.8%; RR 1.17, CI 0.91-1.51); ACEi/ARB prescribed (15.9% vs.16.1%;RR 0.95, CI 0.76-1.18); BP control (20.4% vs. 20.2%;RR 0.98, CI 0.84-1.15); A1C control (21.4% vs. 22.1%;RR 1.00, CI 0.80-1.24); NSAID not on the active medication list (51.5% vs. 50.4%;RR 1.03, CI 0.90-1.17); referral or visit to a nephrologist (38.7% vs. 36.1%;RR 1.02, CI 0.79-1.32). LimitationsWe encountered an overall reduction in expected primary care encounters and obstacles to point-of-care CKD-CDS utilization due to the COVID-19 pandemic. ConclusionThe CKD-CDS intervention did not lead to a significant improvement in CKD quality metrics. The challenges to CDS use during the COVID-19 pandemic likely influenced these results.