Abstract
BackgroundLow adherence to chronic kidney disease (CKD) guidelines may be due to unrecognized CKD and lack of guideline awareness on the part of providers. The goal of this study was to evaluate the impact of provider education and access to a CKD registry on guideline adherence.MethodsWe conducted a cluster randomized controlled trial at the Louis Stokes Cleveland VAMC. One of two primary care clinics was randomized to intervention. Providers from both clinics received a lecture on CKD guidelines at study initiation. Providers in the intervention clinic were given access to and shown how to use a CKD registry, which identifies patients with CKD and is automatically updated daily. Eligible patients had at least one primary care visit in the last year, had CKD based on eGFR, and had not received renal replacement therapy. The primary outcome was parathyroid hormone (PTH) adherence, defined by at least one PTH measurement during the 12 month study. Secondary outcomes were measurement of phosphorus, hemoglobin, proteinuria, achievement of goal blood pressure, and treatment with a diuretic or renin-angiotensin system blocker.ResultsThere were 418 and 363 eligible patients seen during the study in the control and intervention clinics, respectively. Compared to pre-intervention, measurement of PTH increased in both clinics (control clinic: 16% to 23%; intervention clinic: 13% to 28%). Patients in the intervention clinic were more likely to have a PTH measured during the study (adjusted odds ratio = 1.53; 95% CI (1.01, 2.30); P = 0.04). However, the intervention was not associated with a consistent improvement in secondary outcomes. Only 5 of the 37 providers in the intervention clinic accessed the registry.ConclusionsAn intervention that included education on CKD guidelines and access to a CKD patient registry marginally improved guideline adherence over education alone. Adherence to the primary process measure improved in both clinics, but no improvement was seen in intermediate clinical outcomes. Improving the care of patients with CKD will likely require a multifaceted approach including system redesign.ClinicalTrials.Gov registration numberNCT00921687
Highlights
Low adherence to chronic kidney disease (CKD) guidelines may be due to unrecognized CKD and lack of guideline awareness on the part of providers
While adherence to recommended process measures is better amongst patients seen by nephrologists, achieving KDOQI targets is difficult even when patients are seen in dedicated CKD clinics [7,8,9,12]
Twenty of 37 providers (54%) in the intervention clinic and 17 of 33 providers (52%) in the control clinic attended the lecture on CKD guidelines
Summary
Low adherence to chronic kidney disease (CKD) guidelines may be due to unrecognized CKD and lack of guideline awareness on the part of providers. Given the complex nature of CKD, the National Kidney Foundation published the Kidney Disease Outcome Quality Initiative (KDOQI) guidelines to provide a framework for the clinical management of patients with CKD [4]. The KDOQI guidelines make recommendations for the evaluation, monitoring, and management of patients with CKD. Despite the dissemination of the KDOQI guidelines and efforts by the National Kidney Foundation and the American Society of Nephrology to raise awareness of the importance of CKD, adherence to KDOQI recommendations is low [5,6,7,8,9]. While adherence to recommended process measures is better amongst patients seen by nephrologists, achieving KDOQI targets is difficult even when patients are seen in dedicated CKD clinics [7,8,9,12]
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