Automated clinical reminders for primary care providers in the care of CKD: a small cluster-randomized controlled trial.

Abdel-Kader K, Fischer GS, Li J, Moore CG, Hess R, Unruh ML
Am J Kidney Dis. 2011 58 (6): 894-902

PMID: 21982456 · PMCID: PMC3221894 · DOI:10.1053/j.ajkd.2011.08.028

BACKGROUND - Primary care physicians (PCPs) care for most non-dialysis-dependent patients with chronic kidney disease (CKD). Studies suggest that PCPs may deliver suboptimal CKD care. One means to improve PCP treatment of CKD is clinical decision support systems (CDSSs).

STUDY DESIGN - Cluster-randomized controlled trial.

SETTING & PARTICIPANTS - 30 PCPs in a university-based outpatient general internal medicine practice and their 248 patients with moderate to advanced CKD who had not been referred to a nephrologist.

INTERVENTION - 2 CKD educational sessions were held for PCPs in both arms. The 15 intervention-arm PCPs also received real-time automated electronic medical record alerts for patients with estimated glomerular filtration rates <45 mL/min/1.73 m(2) recommending renal referral and urine albumin quantification if not done within the prior year.

OUTCOMES - Primary outcome was referral to a nephrologist; secondary outcomes were albuminuria/proteinuria assessment, CKD documentation, optimal blood pressure (ie, <130/80 mm Hg), and use of renoprotective medications.

RESULTS - The intervention and control arms did not differ in renal referrals (9.7% vs 16.5%, respectively; between-group difference, -6.8%; 95% CI, -15.5% to 1.8%; P = 0.1) or proteinuria assessments (39.3% vs 30.1%, respectively; between-group difference, 9.2%; 95% CI, -2.7% to 21.1%; P = 0.1). For intervention and control patients without a baseline proteinuria assessment, 27.7% versus 16.3%, respectively, had one at follow-up (P = 0.06). After controlling for clustering, these findings were largely unchanged and no significant differences were apparent between groups.

LIMITATIONS - Small single-center university-based practice, use of a passive CDSS that required PCPs to trigger the electronic order set.

CONCLUSIONS - PCPs were willing to partake in a randomized trial of a CDSS to improve outpatient CKD care. Although CDSSs may have potential, larger studies are needed to further explore how best to deploy them to enhance CKD care.

Copyright © 2011 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

MeSH Terms (13)

Aged Decision Support Systems, Clinical Feasibility Studies Female Glomerular Filtration Rate Humans Male Middle Aged Physicians, Primary Care Practice Patterns, Physicians' Quality of Health Care Reminder Systems Renal Insufficiency, Chronic

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