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Abstract: TH-OR051

Pragmatic Cluster-Randomized Trial of an Electronic Clinical Decision Support System (eCDSS) to Improve CKD Management in Primary Care

Session Information

Category: CKD (Non-Dialysis)

  • 2102 CKD (Non-Dialysis): Clinical, Outcomes, and Trials

Authors

  • Peralta, Carmen A., Cricket Health, UCSF, San Francisco, California, United States
  • Robinson, Andrew D., UCSF, San Francisco, California, United States
  • Livaudais-Toman, Jennifer, UCSF, San Francisco, California, United States
  • Stebbins, Marilyn, UCSF, San Francisco, California, United States
  • Scherzer, Rebecca, UCSF, San Francisco, California, United States
  • Lo, Lowell J., UCSF, San Francisco, California, United States
  • Pathak, Sarita, University of California, San Francisco, San Francisco, California, United States
  • Karliner, Leah, UCSF, San Francisco, California, United States
Background

Whether eCDSS improves CKD management in primary care is not well known.

Methods

We conducted a 12-month, 3-arm, pragmatic, cluster-randomized trial to evaluate feasibility and preliminary effectiveness of two eCDSS strategies to improve CKD management in primary care. We used electronic health record to identify participants, deliver intervention, and ascertain outcomes. We randomized 524 adults with two eGFRCr<60 mL/min/1.73m2 ≥90 days apart in clusters by primary care provider (PCP) to: (1) eCDSS; (2) eCDSS plus pharmacist; or (3) usual care. Intervention included risk stratification with creatinine, cystatin C, albumin-to-creatinine ratio, followed by eCDSS embedded in EHR for individually tailored clinical guidance and patient education. eCDSS PLUS added a pharmacist follow up call. Primary clinical outcome was blood pressure (BP) change. Secondary outcomes were PCP CKD awareness, and appropriate use of ACEi/ARB and statin.

Results

All 81 eligible PCPs agreed to participate. Mean patient age was 70, 47% non-white, median eGFRcreat 57 ± 0.6 mL/min/1.73m2. At baseline, there was high use of ACEi/ARB (61%), statin (67%) and BP control (71%). Among intervention patients (n=336), 178 (53%) completed triple-marker labs and 138 (41%) had labs and PCP visit with eCDSS deployed. eCDSS was opened by the PCP for 102/138 (74%) eligible encounters, with at least one suggested order or education material signed for 83/102 (81%). Among eCDSS PLUS 29/40 (73%) completed pharmacist call. After 12 months, BP change (SBP: -2.0 ± 0.9 mmHg; DBP: -0.2 ± 0.4 mmHg), PCP CKD awareness (50%) and use of ACEi/ARB (49%) and statin (56%) were similar across groups. In as-treated analyses, PCP CKD awareness was higher in eCDSS and eCDSS PLUS (73% and 69%) vs. usual care (47%) at study end, adjusted p=0.01.

Conclusion

This tailored, automated CKD eCDSS embedded in the EHR was highly utilized by participating PCPs. Due to insufficient uptake of testing and high baseline guideline-concordant CKD care in the practice, we were unable to determine eCDSS effectiveness to improve CKD management. We did demonstrate increased PCP CKD awareness. This easily usable tool can be used in large pragmatic trials engaging PCPs to improve CKD management.

Funding

  • NIDDK Support