Implementation of a CKD Checklist for Primary Care Providers

Abstract

Background and objectives CKD is associated with significant morbidity, mortality, and financial burden. Practice guidelines outlining CKD management exist, but there is limited application of these guidelines. Interventions to improve CKD guideline adherence have been limited. This study evaluated a new CKD checklist (a tool outlining management guidelines for CKD) to determine whether implementation in an academic primary care clinic improved adherence to guidelines.Design, setting, participants, & measurements During a 1-year period (August 2012-August 2013), a prospective study was conducted among 13 primary care providers (PCPs), four of whom were assigned to use a CKD checklist incorporated into the electronic medical record during visits with patients with CKD stages 1-4. All providers received education regarding CKD guidelines. The intervention and control groups consisted of 105 and 263 patients, respectively. Adherence to CKD management guidelines was measured.Results A random-effects logistic regression analysis was performed to account for intra-group correlation by PCP assignment and adjusted for age and CKD stage. CKD care improved among patients whose PCPs were assigned to the checklist intervention compared with controls. Patients in the CKD checklist group were more likely than controls to have appropriate annual laboratory testing for albuminuria (odds ratio [OR], 7.9; 95% confidence interval [95% CI], 3.6 to 17.2), phosphate (OR, 3.5; 95% CI, 1.5 to 8.3), and parathyroid hormone (OR, 8.1; 95% CI, 4.8 to 13.7) (P,0.001 in all cases). Patients in the CKD checklist group had higher rates of achieving a hemoglobin A1c target,7% (OR, 2.7; 95% CI, 1.4 to 5.1), use of an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker (OR, 2.1; 95% CI, 1.0 to 4.2), documentation of avoidance of nonsteroidal anti-inflammatory drugs (OR, 41.7; 95% CI, 17.8 to 100.0), and vaccination for annual influenza (OR, 2.1; 95% CI, 1.1 to 4.0) and pneumococcus (OR, 4.7; 95% CI, 2.6 to 8.6) (P,0.001 in all cases).Conclusions Implementation of a CKD checklist significantly improved adherence to CKD management guidelines and delivery of CKD care.

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

“…A prospective, nonrandomized study found that a CKD checklist incorporated into the EHR in 1 primary care clinic improved process CQMs such as testing for albuminuria and use of an ACEI/ARB, but not blood pressure control, consistent with the results of this study. 12 In another single-center, cluster-randomized trial, automated reminders for primary care providers did not improve adherence to any outcomes, including assessment of albuminuria or blood pressure control. 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.…”

“…11 Electronic-health record (EHR)-based reminders and clinical decision support (CDS) have been identified as potential tools to improve the identification of CKD, facilitate monitoring, and improve adherence to treatment targets. To date, however, only a few small, single-site studies have evaluated the use of EHR-based tools to improve CKD care, 12,13 and none have assessed provider and staff perceptions of their use. 14,15 This 2-year demonstration study was designed to assess the impact of EHR-based CDS tools on a set of primary care CKD clinical quality measures (CQMs).…”

Checklists as Computer Decision Support at the Point of Care

“…Mendu et al evaluated adherence to an evidencebased CKD computer decision-support checklist in 105 patients treated by four PCPs compared with usual care in 263 patients of nine control PCPs at a single site (7). After being populated with relevant laboratory and clinical parameters unique to the patient, the checklist was e-mailed to the intervention PCP in advance of the outpatient visit as well as incorporated into the EMR for review, annotation, and maintenance in the EMR as a separate note from the visit documentation.…”

“…QI research evaluates a QI intervention group versus a comparison group, using scientific rigor. Another strength of the article by Mendu et al is that the analysis considered confounding variables such as historical performance in implementing evidence-based guidelines and contemporary performance for other measures that were not part of the checklist (7). The extra time and attention necessary for the PCP to improve CKD care did not seem to deleteriously affect performance in other areas of preventive care.…”

“…There are several limitations of this single-center study of 13 PCPs and 368 patients (7). Randomization of the physicians to intervention and control groups would have made this a pragmatic clinical trial.…”