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Background The diagnosis of chronic kidney disease (CKD) is based on laboratory results easily extracted from electronic health records; therefore, CKD identification and management is an ideal area for targeted electronic decision support efforts. Early CKD management frequently occurs in primary care settings where primary care providers (PCPs) may not implement all the best practices to prevent CKD-related complications. Few previous studies have employed randomized trials to assess a CKD electronic clinical decision support system (eCDSS) that provided recommendations to PCPs tailored to each patient based on laboratory results. Objective The aim of this study was to report the trial design and implementation experience of a CKD eCDSS in primary care. Methods This was a 3-arm pragmatic cluster-randomized trial at an academic general internal medicine practice. Eligible patients had 2 previous estimated-glomerular-filtration-rates by serum creatinine (eGFR Cr ) <60 mL/min/1.73m 2 at least 90 days apart. Randomization occurred at the PCP level. For patients of PCPs in either of the 2 intervention arms, the research team ordered triple-marker testing (serum creatinine, serum cystatin-c, and urine albumin-creatinine-ratio) at the beginning of the study period, to be completed when acquiring labs for regular clinical care. The eCDSS launched for PCPs and patients in the intervention arms during a regular PCP visit subsequent to completing the triple-marker testing. The eCDSS delivered individualized guidance on cardiovascular risk-reduction, potassium and proteinuria management, and patient education. Patients in the eCDSS+ arm also received a pharmacist phone call to reinforce CKD-related education. The primary clinical outcome is blood pressure change from baseline at 6 months after the end of the trial, and the main secondary outcome is provider awareness of CKD diagnosis. We also collected process, patient-centered, and implementation outcomes. Results A multidisciplinary team (primary care internist, nephrologists, pharmacist, and informaticist) designed the eCDSS to integrate into the current clinical workflow. All 81 PCPs contacted agreed to participate and were randomized. Of 995 patients initially eligible by eGFR Cr , 413 were excluded per protocol and 58 opted out or withdrew, resulting in 524 patient participants (188 usual care; 165 eCDSS; and 171 eCDSS+). During the 12-month intervention period, 53.0% (178/336) of intervention patient participants completed triple-marker labs. Among these, 138/178 (77.5%) had a PCP appointment after the triple-marker labs resulted; the eCDSS was opened for 73.9% (102/138), with orders or education signed for 81.4% (83/102). Conclusions Successful integration of an eCDSS into primary care workflows and high eCDSS utilization rates at eligible visits suggest ...

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Results from this pilot study indicate the benefits of providing pharmacist-directed services to the population targeted by MTMP services, which encompasses Medicare beneficiaries with multiple chronic diseases, multiple drugs, and high drug costs. By providing pharmacist consultation at the point of care to ensure appropriate drug use, decrease OOP expenditures, and improve access to needed drugs, the PRICE Clinic is a possible model for further development in the implementation of MTMP services.

Despite electronic systems designed to warn dispensing pharmacists of duplications of drug class and cumulative excessive doses, potentially toxic amounts of acetaminophen are commonly prescribed and dispensed to this population. Better systems, increased awareness, and education of patients, prescribers, and pharmacists are needed to reduce this potential toxic exposure.

Objectives. To determine whether a peer-to-peer education program was an expedient and effective approach to improve knowledge and promote interprofessional communication and collaboration. Design. Trained pharmacy students taught nursing students, medical students, and medical residents about the Medicare Part D prescription drug benefit (Part D), in 1-to 2-hour lectures. Assessment. Learners completed a survey instrument to assess the effectiveness of the presentation and their attitudes toward the peer-to-peer instructional format. Learners strongly or somewhat agreed that the peer-to-peer format was effective in providing Part D education (99%) and promoted interprofessional collaboration (100%). Qualitative data highlighted the program's clinical relevance, value in promoting interprofessional collaboration, and influence on changing views about the roles and contributions of pharmacists. Conclusion. The Part D peer educator program is an innovative way to disseminate contemporary health policy information rapidly, while fostering interprofessional collaboration.

Most adults with chronic kidney disease (CKD) in the United States are cared for by primary care providers (PCPs). We evaluated the feasibility and preliminary effectiveness of an electronic clinical decision support system (eCDSS) within the electronic health record with or without pharmacist follow-up to improve the management of CKD in primary care. Study Design: Pragmatic cluster-randomized trial. Setting & Participants: 524 adults with confirmed creatinine-based estimated glomerular filtration rates of 30 to 59 mL/min/1.73 m 2 cared for by 80 PCPs at the University of California San Francisco. Electronic health record data were used for patient identification, intervention deployment, and outcomes ascertainment. Interventions: Each PCP's eligible patients were randomly assigned as a group into 1 of 3 treatment arms: (1) usual care; (2) eCDSS: testing of creatinine, cystatin C, and urinary albumincreatinine ratio with individually tailored guidance for PCPs on blood pressure, potassium, and proteinuria management, cardiovascular risk reduction, and patient education; or (3) eCDSS plus pharmacist counseling (eCDSS-PLUS). Outcomes: The primary clinical outcome was change in blood pressure over 12 months. Secondary outcomes were PCP awareness of CKD and use of angiotensin-converting enzyme inhibitor/ angiotensin receptor blocker and statin therapy. Results: All 80 eligible PCPs participated. Mean patient age was 70 years, 47% were nonwhite, and mean estimated glomerular filtration rate was 56 ± 0.6 mL/min/1.73 m 2. Among patients receiving eCDSS with or without pharmacist counseling (n = 336), 178 (53%) completed laboratory measurements and 138 (41%) had laboratory measurements followed by a PCP visit with eCDSS deployment. eCDSS was opened by the PCP for 102 (74%) patients, with at least 1 suggested order signed for 83 of these 102 (81%). Changes in systolic blood pressure were −2.1 ± 1.5 mm Hg with usual care, −2.8 ± 1.8 mm Hg with eCDSS, and −1.1 ± 1.1 with eCDSS-PLUS (P = 0.7). PCP awareness of CKD was 16% with usual care, 26% with eCDSS, and 32% for eCDSS-PLUS (P = 0.09). In as-treated analyses, PCP awareness of CKD was significantly greater with eCDSS and eCDSS-PLUS (73% and 69%) versus usual care (47%; P = 0.002). Limitations: Recruitment of smaller than intended sample size and limited uptake of the testing component of the intervention. Editorial, p. 613 Complete author and article information provided before references.

Findings show that targeted outreach by trained pharmacy advocates can identify vulnerable Medicare populations in need of Part D counseling and reduce their expected annual OOP prescription drug costs.