A Risk Based Approach to Improving Management of Chronic Kidney Disease (Massachusetts)

Project Final Report (PDF, 372.21 KB) Disclaimer

Project Details - Ended

Project Categories

Summary:

Although primary care represents the front line in the early identification and management of chronic kidney disease (CKD), it is often unrecognized by primary care physicians (PCPs). Effective management of earlier stage CKD reduces mortality rates and the costs associated with progression to advanced kidney failure. Existing clinical practice guidelines promote monitoring for progressive kidney disease, as well as aggressive management of cardiovascular risk and the complications of metabolic bone disease and anemia. The overall goal of this study was to implement a program to improve the quality of CKD care using disease registries and decision support tools within an advanced electronic health record.

The specific aims of this project were to:

  • Use computerized clinical information systems to identify baseline predictors of appropriate evaluation and treatment of Stages 3 and 4 chronic kidney disease, including patient characteristics and nephrology involvement.
  • Assess whether quality of care for Stage 3 chronic kidney disease can be substantially improved over 18 months by: 1) point-of-care electronic alerts to primary care physicians recommending risk-appropriate care; and 2) quarterly mailings to patients providing self-management support materials, including tailored recommendations based on personalized data from an electronic disease registry.
  • Assess the relationship between utilization of the intervention components and primary care physician attitudes toward both chronic kidney disease management and electronic reminder systems.

A randomized trial of 9,502 primary care patients with CKD cared for by 158 PCPs at a multispecialty integrated group practice was conducted. The PCPs were randomly assigned to receive a set of electronic alerts that recommended risk-appropriate care for patients with CKD. Physicians in the intervention group were also given the option to enroll patients in a self-management support program consisting of quarterly tailored mailings. Primary outcomes for the study included: 1) a visit to a nephrologist (high-risk patients); 2) initiation of an angiotensin converting enzyme (ACE) inhibitor (high and low risk patients); and 3) performance of annual urine protein screening (low-risk patients).

Intervention physicians enrolled 22 percent of their patients in the educational mailing program. High risk patients of intervention physicians were more likely to be evaluated by a nephrologist than were high-risk patients in the control group. This effect was particularly pronounced among patients who received the educational mailings and those with increasing numbers of primary care visits. Use of ACE inhibitors was not increased among either high- or low-risk patients, though use was increased among patients who received educational mailings. Low-risk patients of intervention physicians were more likely to receive annual urine protein screening than were patients of control physicians.

The researchers found that their program significantly improved quality of care for both high- and low-risk patients with CKD—increasing the collaborative care with nephrologists, improving disease monitoring through appropriate laboratory testing, and in some cases, increasing use of appropriate medications. The program was well received by PCPs and patients responded positively to the educational mailings.

A Risk Based Approach to Improving Management of Chronic Kidney Disease - 2012

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS08-270: Utilizing Health IT to Improve Health Care Quality Grant (R18)
  • Grant Number: 
    R18 HS 018226
  • Project Period: 
    December 2009 - July 2013
  • AHRQ Funding Amount: 
    $1,127,741
  • PDF Version: 
    (PDF, 198.23 KB)

Summary: Chronic kidney disease (CKD), though common, is often unrecognized by primary care physicians (PCPs). While better health outcomes can be obtained with better disease identification and management, there has been limited review of the outcomes of comprehensive disease management of CKD and no studies of the impact of patient education on this condition. A research team at Harvard Vanguard Medical Associates, an integrated delivery system in Massachusetts, conducted a randomized controlled study on the care of patients with Stages 3 and 4 CKD in the primary care setting. The study implemented a disease management program at 14 health centers with improved clinical decision support for physicians and self-management support for patients.

During the first phase of this project in 2010, one health center was selected to pilot test the clinical decision- and patient-support materials. The randomized controlled trial was conducted over 18 months and included approximately 170 providers. The physicians in the intervention group received patient-specific alerts at the time of office visits; the control group physicians did not.

The impact of combining electronic alerts, a disease registry, and a patient-education program on adherence to best treatment practices is being measured by several indicators, including problem lists and encounter codes. Assessment of the appropriate documented problem list and encounter codes is being used to measure PCP awareness of CKD. Providers are also being queried on how the use of the intervention tools affected their attitude about CKD management and the use of electronic reminder systems. Data for the study will be taken for patients with CKD from Harvard Vanguard’s electronic health record (EHR). The data will provide information on best practices in the treatment of CKD in the primary care setting through the use of EHRs, advanced decision support, and patient outreach and education.

Specific Aims:

  • Use computerized clinical information systems to identify baseline predictors of appropriate evaluation and treatment of Stages 3 and 4 chronic kidney disease, including patient characteristics and nephrology involvement. (Achieved)
  • Assess whether quality of care for Stage 3 chronic kidney disease can be substantially improved over 18 months by: 1) point-of-care electronic alerts to primary care physicians recommending risk-appropriate care; and 2) quarterly mailings to patients providing self-management support materials, including tailored recommendations based on personalized data from an electronic disease registry. (Ongoing)
  • Assess the relationship between utilization of the intervention components and primary care physician attitudes toward both chronic kidney disease management and electronic reminder systems. (Upcoming)

2012 Activities: The 18-month randomized trial started in spring 2011 with completion planned for January 2013. The intervention included physician alerts recommending risk-appropriate care and mailing of patient support materials for those with CKD. Clinical practice site start dates were staggered in phases, but all conducted the intervention for 18 months. The trial was extended for some practices so that all practices would complete in the same month. Of the 8,000 patients in the trial, about 4,000 were in the intervention arm and 1,200 were enrolled in the patient-education mailing program. The patients in the mailing program received an initial baseline survey to assess the quality of the patient-education materials and provider education, and will receive a followup survey in January 2013. The research team developed followup surveys to assess provider attitudes at the conclusion of the trial; this was submitted for institutional review board approval.

Throughout the clinical trial, the time between the primary care provider placing an order for a nephrologist and the time of the nephrologist appointment was tracked: all patients have been seen within the 45-day goal. This was important because in the pilot phase of the project, the increase in referrals generated by the implementation of the electronic alerts led to longer than desirable wait times for the nephrology appointments.

A 12-month no-cost extension was used to complete the clinical trial and conduct data analysis. As last self-reported in the AHRQ Research Reporting System, project progress is completely on track and project budget spending is roughly on target.

Preliminary Impact and Findings: In the first phase of research, the project team analyzed the predictors of quality of CKD care. The analysis found that among 11,760 patients treated by 166 PCPs across 15 clinics, 66 percent had hypertension and 29 percent had diabetes. PCP awareness of CKD was low, at 24 percent, and only 10 percent of patients were co-managed with nephrologists. Most patients were not receiving appropriate CKD care, and both PCP awareness and nephrology co-management were consistently associated with improved effectiveness and drug safety.

The completed pilot intervention provided several insights into implementing the larger scale intervention. These included: 1) the volume of nephrology referrals generated through electronic alerts; 2) patient reactions to educational mailing materials; and 3) provider reactions to the electronic alerts.

Target Population: Chronic Care*, Kidney Disease

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation

* This target population is one of AHRQ’s priority populations.

A Risk Based Approach to Improving Management of Chronic Kidney Disease - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS08-270: Utilizing Health IT to Improve Health Care Quality Grant (R18)
  • Grant Number: 
    R18 HS 018226
  • Project Period: 
    December 2009 - November 2012
  • AHRQ Funding Amount: 
    $1,127,741
  • PDF Version: 
    (PDF, 207.7 KB)

Summary: Chronic kidney disease (CKD), though common, is often unrecognized by primary care physicians. While better health outcomes can often be obtained with better disease identification and management, there has been limited review of the outcomes of comprehensive disease management of CKD and no studies of the impact of patient education on this condition. A research team at Harvard Vanguard Medical Associates, an integrated delivery system in Massachusetts, is conducting a randomized controlled study on the care of patients with stage 3 CKD in the primary care setting. The study implements a disease management program at 14 health centers with improved clinical decision support for physicians and self-management support for patients.

During the first phase of this project in 2010, one health center was selected to pilot test the clinical decision and patient support materials. The randomized controlled trial is being conducted over 18 months and will include approximately 170 providers. The physicians in the intervention group will receive patient-specific alerts at the time of office visits, while the control group physicians will not.

The impact of combining electronic alerts, a disease registry, and a patient-education program on adherence to best treatment practices will be measured by several indicators, including problem lists and encounter codes. Assessment of the appropriate documented problem list and encounter codes will be used to measure primary care physician awareness of CKD. Providers will also be queried on how the use of the intervention tools affected their attitude about CKD management and the use of electronic reminder systems. Data for the study will be taken for patients with CKD from the electronic records in Harvard Vanguard's 2007 EpicCare electronic health record (EHR). The data will provide information on best practices in the treatment of CKD in the primary care setting through the use of EHRs, advanced decision support, and patient outreach and education.

Specific Aims:

  • Use computerized clinical information systems to identify baseline predictors of appropriate evaluation and treatment of stages 3 and 4 chronic kidney disease, including patient characteristics and nephrology involvement. (Achieved)
  • Assess whether quality of care for stage 3 chronic kidney disease can be substantially improved over 18 months by: 1) point-of-care electronic alerts to primary care physicians recommending risk-appropriate care; and 2) quarterly mailings to patients providing self-management support materials, including tailored recommendations based on personalized data from an electronic disease registry. (Ongoing)
  • Assess the relationship between utilization of the intervention components and primary care physician attitudes towards both chronic kidney disease management and electronic reminder systems. (Upcoming)

2011 Activities: The 18-month randomized trial started in spring 2011. The intervention included physician alerts recommending risk-appropriate care and the mailing of patient support materials for those with CKD. In April and each following month, two clinical practice sites were initiated into the trial until all 14 sites were included. The phased initiation of sites addressed the potentially overwhelming number of nephrology referrals generated by the clinical decision support component of the intervention. During the pilot, the clinical decision support generated an increased number of nephrology referrals and the research team worked with nephrology department to ensure there was adequate capacity. A patient survey was completed and initiated with the start of the randomized trial to assess the quality of mailed patient self-support tools for chronic kidney disease and the quality of provider counseling on disease management. As last self-reported in the AHRQ Research Reporting System, project progress is mostly on track. The project budget funds to date are somewhat underspent due to delayed timing of patient mailings.

Preliminary Impact and Findings: In the first phase of research, the project team analyzed the predictors of quality of CKD care. The analysis found that among 11,760 patients treated by 166 primary care providers (PCPs) across 15 clinics, 66 percent had hypertension and 29 percent had diabetes. PCP awareness of CKD was low, at 24 percent, and only 10 percent of patients were co-managed with nephrologists. Most patients were not receiving appropriate CKD care, and both PCP awareness and nephrology co-management were consistently associated with improved effectiveness and drug safety.

The completed pilot intervention provided several insights into implementing the larger scale intervention. These included: 1) the volume of nephrology referrals generated through electronic alerts; 2) the patient reactions to educational mailing materials; and 3) the provider reactions to the electronic alerts.

Target Population: Chronic Care*, Kidney Disease

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation

* This target population is one of AHRQ's priority populations.

A Risk Based Approach to Improving Management of Chronic Kidney Disease - 2010

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS08-270: Utilizing Health IT to Improve Health Care Quality Grant (R18)
  • Grant Number: 
    R18 HS 018226
  • Project Period: 
    December 2009 – November 2012
  • AHRQ Funding Amount: 
    $1,127,741
  • PDF Version: 
    (PDF, 398.66 KB)


Target Population: Chronic Care*, Kidney Disease

Summary: Chronic kidney disease (CKD), though common, is often unrecognized by primary care physicians. Better health outcomes can often be obtained with better disease identification and management. However, there has been limited review of the outcomes of comprehensive disease management of CKD and no studies of the impact of patient education on this condition. Harvard Vanguard Medical Associates, an integrated delivery system in Massachusetts, is conducting a randomized controlled study on the care of patients with stage 3 CKD in the primary care setting. The study implements a disease management program at 14 health centers with improved clinical decision support for physicians and self-management support for patients.

During the first phase of the project, one health center was selected for pilot testing the intervention components including the clinical decision support and patient support materials. The randomized controlled trial will be conducted over 18 months, and will include approximately 170 providers. The physicians in the intervention group will receive patient-specific alerts at the time of office visits, while the control group physicians will not.

The impact of combining electronic alerts, a disease registry, and a patient education program on adherence to best treatment practices, will be measured by several indicators such as problem lists and encounter codes. Assessment of the appropriate documented problem list and encounter codes will be used to measure primary care physician awareness of CKD. Providers will also be queried on how the use of the intervention tools impacted their attitude towards CKD management and the use of electronic reminder systems. Data for the study will be taken for patients with CKD from the electronic records in Harvard Vanguard’s 2007 EpicCare electronic health record (EHR), which is certified by the Certification Commission for Healthcare Information Technology. The data will provide information on best practices in the treatment of CKD in the primary care setting through the use of EHRs, advanced decision support, and patient outreach and education.

Specific Aims:
  • Use computerized clinical information systems to identify baseline predictors of appropriate evaluation and treatment of stages 3 and 4 chronic kidney disease, including patient characteristics and nephrology involvement. (Achieved)
  • Assess whether quality of care for stage 3 chronic kidney disease can be substantially improved over 18 months by: a) point of care electronic alerts to primary care physicians recommending risk-appropriate care, and b) quarterly mailings to patients providing self-management support materials, including tailored recommendations based on personalized data from an electronic disease registry. (Ongoing)
  • Assess the relationship between utilization of the intervention components and primary care physician attitudes towards both chronic kidney disease management and electronic reminder systems. (Upcoming)

2010 Activities: In June a pilot of the intervention was initiated. The pilot included physician alerts and the mailing of patient support materials. For providers, the pilot randomized five physicians to receive electronic alerts. Prior to “turning on” the electronic alerts, the physicians were surveyed on their perceptions of electronic reminder systems, patient self-management support, and physician preparedness for managing CKD. A clinical database was constructed, which populated information fields within personalized letters to be included in the patient mailings. The grantee team also created a baseline and followup survey. The randomized controlled clinical trial is scheduled to begin early in 2011.

Grantee's Most Recent Self-Reported Quarterly Status (as of December 2010): The project is meeting 80 to 99 percent of the planned milestones on time. The project spending to date is somewhat under budget due to delayed timing of patient mailings.

Preliminary Impact and Findings: In the first phase of research the team analyzed the predictors of quality of CKD care. The findings from this analysis were that among 11,760 patients treated by 166 primary care providers (PCPs) across 15 clinics, 66 percent had hypertension and 29 percent had diabetes. PCP awareness of CKD was low at 24 percent, and only 10 percent of patients were co-managed with nephrologists. Most patients were not receiving appropriate CKD care, and both PCP awareness and nephrology co-management were consistently associated with improved effectiveness and drug safety.

The completed pilot intervention provided several insights into implementing the larger scale intervention. These included: 1) the volume of nephrology referrals generated through electronic alerts; 2) the patient reactions to educational mailing materials; and 3) the provider reactions to the electronic alerts. These findings will inform the full randomized trial scheduled to begin in April 2011. The pilot intervention practices increased the number of nephrology referrals 15 fold from the control practices. Due to the increase in nephrology referrals, the research team decided to roll out the intervention in a staged manner across the 14 health centers. By enrolling two health centers per month, the expectation is that the volume of referrals generated through the intervention will be more manageable for the available nephrologists.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation

*AHRQ Priority Population.

A Risk Based Approach to Improving Management of Chronic Kidney Disease - Final Report

Citation:
Sequist T. A Risk Based Approach to Improving Management of Chronic Kidney Disease - Final Report. (Prepared by Brigham and Women's Hospital under Grant No. R18 HS018226). Rockville, MD: Agency for Healthcare Research and Quality, 2013. (PDF, 372.21 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
Principal Investigator: 
Document Type: 
Population: 
Medical Condition: 
This project does not have any related resource.
This project does not have any related survey.
This project does not have any related project spotlight.
This project does not have any related survey.
This project does not have any related story.
This project does not have any related emerging lesson.