Impact of Estimated GFR Reporting on Patients, Clinicians, and Health-Care Systems: A Systematic Review

Kagoma, Yoan K.; Weir, Matthew A.; Iansavichus, Arthur V.; Hemmelgarn, Brenda R.; Akbari, Ayub; Patel, Uptal D.; Garg, Amit X.; Jain, Arsh K.

doi:10.1053/j.ajkd.2010.08.029

Cited by 70 publications

(68 citation statements)

References 31 publications

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“…In another study, implementation of automatic reporting of eGFR with an educational intervention increased CKD documentation from 22.4% to 88.1% (5). A systematic review of the impact of eGFR reporting showed an increase in nephrology referral after implementation in 13 of 16 studies, particularly in populations at risk for under-recognized disease, including women and the elderly (11). However, in our study, 22.2% of males and 30.4% of females with stage 4 CKD or higher (a point at which the SCr would clearly be abnormal) had undocumented CKD, suggesting an issue beyond translation of SCr to eGFR.…”

Section: Discussionmentioning

confidence: 99%

“…A cohort study looking at patterns of nephrology referral before and after implementation of automatic eGFR reporting found an increase in the monthly adjusted rate of first nephrology outpatient visits only in females (24). In a systematic review of eGFR reporting, eight of nine studies showed that eGFR reporting led to an increase in the number of female patients referred (11). These studies suggest that automatic reporting of eGFR is important for practitioners recognizing CKD in females.…”

Section: Discussionmentioning

confidence: 99%

“…The use of automatic reporting of estimated GFR (eGFR) is controversial (9,10), and results evaluating its implementation on improving CKD recognition have been variable (5,7,11).…”

Section: Introductionmentioning

confidence: 99%

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Documentation and Management of CKD in Rural Primary Care

Rao

Morris

O’Malley³

et al. 2013

Clinical Journal of the American Society of Nephrology

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SummaryBackground and objectives Recognition of CKD by primary care practitioners is essential in rural communities where nephrology access is limited. This study determined the prevalence of undocumented CKD in patients cared for in rural primary care practices and evaluated characteristics associated with undocumented CKD as well as CKD management.Design, setting, participants, & measurements A retrospective cohort study, conducted within the Oregon Rural Practice Based Research Network, consisted of 865 CKD patients with serum creatinine$1.5 mg/dl in males and $1.3 mg/dl in females and an estimated GFR,60 ml/min per 1.73 m 2 . Documentation of a CKD diagnosis and laboratory values were abstracted by chart review.Results Of CKD patients, 51.9% had no documentation of CKD. Undocumented CKD occurred more frequently in female patients (adjusted odds ratio=2.93, 95% confidence interval=2.04, 4.21). The association of serum creatinine reporting versus automating reporting of estimated GFR on CKD documentation was dependent on patient sex, years of practitioner experience, and practitioner clinical training. Hypertensive patients with documented CKD were more likely to have a BP medication change than patients with undocumented CKD (odds ratio=2.07, 95% confidence interval=1.15, 3.73). Only 2 of 449 patients with undocumented CKD were comanaged with a nephrologist compared with 20% of patients with documented CKD (odds ratio=53.20, 95% confidence interval=14.90, 189.90).Conclusions Undocumented CKD in a rural primary care setting is frequent, particularly in female patients. Depending on practitioner characteristics, automatic reporting of estimated GFR might improve documentation of CKD in this population.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Documentation and Management of CKD in Rural Primary Care

Rao

Morris

O’Malley³

et al. 2013

Clinical Journal of the American Society of Nephrology

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“…Appropriate changes in drug dose and prescription, also not available here, could provide another marker of provider awareness of CKD. A recent literature review 17 showed that nephrology referrals increased 13-270 % after institution of automated eGFR reporting, but change in the use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (which can help prevent CKD progression as well as control blood pressure) only increased 0-6 %. Similarly, a retrospective cohort study of predialysis care showed that comanagement of CKD by primary care providers and nephrologists increased from 23 % to 49 % post-eGFR reporting, resulting in greater NSAID avoidance and phosphorus and parathyroid hormone testing, but angiotensin-converting enzyme inhibitors/angiotensin receptor blocker use or urinary albumin testing remained unchanged.…”

Section: Discussionmentioning

confidence: 99%

Chronic Kidney Disease Identification in a High-Risk Urban Population: Does Automated eGFR Reporting Make a Difference?

et al. 2012

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Whether automated estimated glomerular filtration rate (eGFR) reporting for patients is associated with improved provider recognition of chronic kidney disease (CKD), as measured by diagnostic coding of CKD in those with laboratory evidence of the disease, has not been explored in a poor, ethnically diverse, highrisk urban patient population. A retrospective cohort of 237 adult patients (≥20 years) with incident CKD (≥1 eGFR ≥60 ml/min/1.73 m 2 , followed by ≥2 eGFRs G60 ml/min/1.73 m 2 ≥3 months apart)-pre-or postautomated eGFR reporting-was identified within the San Francisco Department of Public Health Community Health Network (January 2005-July 2009). Patients were considered coded if any ICD-9-CM diagnostic codes for CKD (585.x), other kidney disease (580.x-581.x, 586.x), or diabetes (250.4) or hypertension (403.x, 404.x) CKD were present in the medical record within 6 months of incident CKD. Multivariable logistic regression was used to obtain adjusted odds ratios (ORs) for CKD coding. We found that, pre-eGFR reporting, 42.5 % of incident CKD patients were coded for CKD. Female gender, increased age, and non-Black race were associated with lower serum creatinine and lower prevalence of coding but comparable eGFR. Prevalence of coding was not statistically significantly higher overall (49.6 %, P=0.27) or in subgroups after the institution of automated eGFR reporting. However, gaps in coding by age and gender were narrowed post-eGFR, even after adjustment for sociodemographic and clinical characteristics: 47.9 % of those G65 and 30.3 % of those ≥65 were coded pre-eGFR, compared to 49.0 % and 52.0 % post-eGFR (OR = 0.43 and 1.16); similarly, 53.2 % of males and 25.4 % of females were coded preeGFR compared to 52.8 % and 44.0 % post-eGFR (OR 0.28 vs. 0.64). Blacks were more likely to be coded in the post-eGFR period: OR=1.08 and 1.43 (P interaction 9 0.05). Automated eGFR reporting may help improve CKD recognition, but it is not sufficient to resolve underidentification of CKD by safety net providers.

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“…Similar to conditions such as dyslipidemia (for which information to aid physicians with interpretation often accompanies laboratory results), there has been widespread enthusiasm for the use of laboratory prompts to facilitate recognition of CKD (16). Accordingly, many jurisdictions have implemented eGFR reporting, meaning that eGFR is also reported when a provider requests serum creatinine measurements (16,17).…”

Section: Introductionmentioning

confidence: 99%

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

Manns

Tonelli

Culleton

et al. 2012

Clinical Journal of the American Society of Nephrology

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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.

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Impact of Estimated GFR Reporting on Patients, Clinicians, and Health-Care Systems: A Systematic Review

Cited by 70 publications

References 31 publications

Documentation and Management of CKD in Rural Primary Care

Documentation and Management of CKD in Rural Primary Care

Chronic Kidney Disease Identification in a High-Risk Urban Population: Does Automated eGFR Reporting Make a Difference?

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

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