A Cluster Randomized Trial of an Enhanced eGFR Prompt in Chronic Kidney Disease

Abstract

SummaryBackground and objectives Despite reporting estimated GFR (eGFR), use of evidence-based interventions in CKD remains suboptimal. This study sought to determine the effect of an enhanced eGFR laboratory prompt containing specific management recommendations, compared with standard eGFR reporting in CKD.Design, setting, participants, & measurements A cluster randomized trial of a standard or enhanced eGFR laboratory prompt was performed in 93 primary care practices in Alberta, Canada. Although all adult patients with CKD (eGFR ,60 ml/min per 1.73 m 2 ) were included, medication data were only available for elderly patients (aged $66 years). The primary outcome, the proportion of patients with diabetes or proteinuria receiving an angiotensin converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB), was assessed in elderly CKD patients.Results There were 5444 elderly CKD patients with diabetes or proteinuria who were eligible for primary outcome assessment, irrespective of baseline ACEi/ARB use. ACEi/ARB use in the subsequent year was 77.1% and 76.9% in the standard and enhanced prompt groups, respectively. In the subgroup of elderly patients with an eGFR ,30 ml/min per 1.73 m 2 , ACEi/ARB use was higher in the enhanced prompt group. Among 22,092 CKD patients, there was no difference in the likelihood of a composite clinical outcome (death, ESRD, doubling of serum creatinine, or hospitalization for myocardial infarction, heart failure, or stroke) over a median of 2.1 years.Conclusions In elderly patients with CKD and an indication for ACEi/ARB, an enhanced laboratory prompt did not increase use of these medications.

Use of Clinical Decision Support to Improve Primary Care Identification and Management of Chronic Kidney Disease (CKD)

“…13 Similarly, a larger cluster-randomized trial of an enhanced laboratory prompt outside the EHR did not effectively improve adherence to CKD clinical practice guidelines. 20 This study has several limitations. First, the study was conducted within a small group of practices that had volunteered to participate, without a control group.…”

Dosing Errors in Prescribed Antibiotics for Older Persons With CKD: A Retrospective Time Series Analysis

“…However, in a recent cluster randomized trial, including management recommendations in the eGFR prompt did not increase the use of kidney-protective medications. 38 An alternative approach of computerized clinical decision support shows promise in improving prescribing patterns. 39 As more primary care physicians adopt electronic medical records, the optimal use of such systems requires consideration.…”

Clinical implications of the CKD epidemiology collaboration (CKD-EPI) equation compared with the modification of diet in renal disease (MDRD) study equation for the estimation of renal dysfunction in patients with cardiovascular disease

“…First, the observation period is long, and in this time, we cannot know if clinicians have changed the behavior during the observation period, especially with the accumulation of evidence on the best performance of the CKD-EPI equation compared to the MDRD appeared in recent years. Second, in our center, the value of GFR is not automatically reported by the laboratory, and provision of this information may influence the level of awareness of the clinician, although two recent studies fail to find this [32,33]. Third, given the clinical profile of patients with CKD, we cannot exclude that a proportion of older patients with multiple comorbidities were in a terminal state, so the doctor did not consider it necessary to point out the presence of CKD.…”