RESEARCH - QUALITY IMPROVEMENT
Implementing an evidence-based clinical decision support tool to improve the detection, evaluation, and referral patterns of adult chronic kidney disease patients in primary care
Mary E. Regan DNP, CRNP,
Corresponding Author
Mary E. Regan DNP, CRNP
(Nurse Practitioner and Primary Care Provider)
General Internal Medicine of Lancaster, Lancaster, Pennsylvania
Correspondence
Mary E. Regan, DNP, CRNP, General Internal Medicine of Lancaster, 2301 Columbia Ave, Lancaster, PA 17603. Tel: 717-397-2738; Fax: 717-397-7634; E-mail: [email protected]
Search for more papers by this authorMary E. Regan DNP, CRNP,
Corresponding Author
Mary E. Regan DNP, CRNP
(Nurse Practitioner and Primary Care Provider)
General Internal Medicine of Lancaster, Lancaster, Pennsylvania
Correspondence
Mary E. Regan, DNP, CRNP, General Internal Medicine of Lancaster, 2301 Columbia Ave, Lancaster, PA 17603. Tel: 717-397-2738; Fax: 717-397-7634; E-mail: [email protected]
Search for more papers by this authorAbstract
Background and purpose
Chronic kidney disease (CKD) is undertreated and under-recognized in primary care. The majority of primary care providers (PCPs) are not aware or knowledgeable of current CKD guidelines. The purpose of this project was to develop a quality improvement intervention for PCPs through the delivery of evidence-based guidelines at the point of care.
Methods
An evidence-based clinical algorithm was developed in the electronic medical record for providers to access within one organization comprising 11 primary care offices with 80 PCPs. Baseline knowledge surveys and baseline data were obtained in August 2016. A CKD educational intervention and tutorial on a clinical decision support (CDS) tool was presented to physicians, nurse practitioners, and physician assistants. Postimplementation data and knowledge surveys were collected in December 2016.
Conclusions
Most PCPs were willing to use a CKD CDS tool to help them with CKD patients. A CDS tool in addition to an educational intervention can improve PCP knowledge and identification of CKD and early referral to nephrology.
Implications for practice
CDS tools can promote evidence-based guided care for PCPs and CKD patients. By using these applications, patients can be properly identified, managed, treated, and appropriately referred to nephrology.
Supporting Information
| Filename | Description |
|---|---|
| jaan12505-sup-0001-Appendix.docx21.5 KB | Appendix A Appendix B |
Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
References
- Abdel-Kader, K., Greer, R., Boulware, E., & Unruh, M. (2014). Primary care physicians' familiarity, beliefs, and perceived barriers to practice guidelines in non-diabetic CKD: A survey study. BMC Nephrology, 15(64), 1–9. Retrieved from https://doi.org/10.1186/1471-2369-15-64
- Agrawal, V., Ghosh, A. K., Barnes, M. A., & McCullough, P. A. (2008). Awareness and knowledge of clinical practice guidelines for CKD among internal medicine residents: A national online survey. American Journal of Kidney Disease, 52(6), 1061–1069. Retrieved from https://doi.org/10.1053/j.ajkd.2008.06.022
- Berns, J. S. (2014). Routine screening for CKD should be done in asymptomatic adults…selectively. Clinical Journal of the American Society of Nephrology, 9(11), 1988–1992. Retrieved from https://doi.org/10.2215/CJN.02250314
- Boulware, L. E., Troll, M. U., Jaar, B. G., Myers, D. I., & Powe, N. R. (2006). Identification and referral of patients with progressive CKD: A national study. American Journal of Kidney Disease, 48(2), 192–302. Retrieved from https://doi.org/10.1053/j.ajkd.2006.04.073
- Bowling, C. B., & O'Hare, A. M. (2012). Managing older adults with CKD: Individualized versus disease-based approaches. American Journal of Kidney Disease, 59(2), 293–302. Retrieved from https://doi.org/10.1053/j.ajkd.2011.08.039
- Centers for Disease Control and Prevention (CDC). (2013). Centers for Medicare and Medicaid: Percentage of patients with ICD-9-CM codes indicating CKD. Retrieved from https://nccd.cdc.gov/CKD/detail.aspx?Qnum=Q79&Strat=Code,Diabetes#refreshPosition
- Centers for Disease Control and Prevention (CDC). (2014). National chronic kidney disease fact sheet. Retrieved from https://www.cdc.gov/diabetes/pubs/pdf/kidney_factsheet.pdf
- Chan, M. R., Dall, A. T., Fletcher, K., Lu, N., & Trivedi, H. (2007). Outcomes in patients with chronic kidney disease referred late to nephrologists: A meta-analysis. American Journal of Medicine, 120(12), 1063–1070. Retrieved from https://doi.org/10.1016/j.amjmed.2007.04.024
- S. L. Dearholt, & D. Dang (2012) (Eds.). Johns Hopkins nursing evidence-based practice: Model and guidelines ( 2nd ed.). Indianapolis: Sigma Theta Tau International.
- Drawz, P. E., Archdeacon, P., McDonald, C. J., Powe, N. R., Smith, K. A., Norton, J., … Narva, A. (2015). CKD as a model for improving chronic disease care through electronic health record. Clinical Journal of the American Society of Nephrology, 10(8), 1488–1499. Retrieved from https://doi.org/10.2215/CJN.00940115
- Dunkler, D., Gao, P., Lee, S. F., Heinze, G., Clase, C. M., Tobe, S., … Oberbauer, R. (2015). Risk prediction for early CKD in type 2 diabetes. Clinical Journal of the American Society of Nephrology, 10(8), 1371–1379. Retrieved from https://doi.org/10.2215/CJN.10321014
- Ennis, J., Gillen, D., Rubenstein, A., Worcester, E., Brecher, M. E., Asplin, J., & Coe, F. (2015). Clinical decision support improves physician guideline adherence for laboratory monitoring of chronic kidney disease: A matched cohort study. BMC Nephrology, 16(163), 1–11. Retrieved from https://doi.org/10.1186/s12882-015-0159-5
- Estrella, M. M., Jaar, B. G., Cavanugh, K. L., Fox, C. H., Perazella, M. A., Soman, S. S., … Choi, M. J. (2013). Perceptions and use of the National Kidney Foundation KDOQI guidelines: A survey of U.S. renal healthcare providers. BMC Nephrology, 14(1), 1–9. Retrieved from https://doi.org/10.1186/1471-2369-14-230
- Fink, H. A., Ishani, A. I., Taylor, B. C., Greer, N. L., MacDonald, R., Rossini, D., … Kane, R. L. (2012). Screening for, monitoring, and treatment of chronic kidney disease stages 1 to 3: A systematic review for the U.S. Preventive Services Task Force and for an American College of Physicians clinical practice guideline. Annals of Internal Medicine, 156(8), 570–581. Retrieved from https://doi.org/10.7326/0003-4819-156-8-201204170-00004
- Fischer, M. J., Ahya, S. N., & Gordan, E. J. (2011). Interventions to reduce late referrals. American Journal of Nephrology, 33(1), 60–69. Retrieved from https://doi.org/10.1159/00322704
- Fox, C., Vest, B., Kahn, L., Dickinson, L., Fang, H., Pace, W., … Vassalotti, J. (2013). Improving evidence-based primary care for chronic kidney disease: Study protocol for a cluster randomized control trial for translating evidence into practice (TRANSLATE CKD). Implementation Science, 8(88), 2–9. Retrieved from https://doi.org/10.1186/1748-5908-8-88
- Fox, C. H., Swanson, A., Kahn, L. S., Glaser, K., & Murray, B. M. (2008). Improving chronic kidney disease care in primary care practices: An upstate New York practice-based research network (UNYNET) study. Journal of the American Board of Family Medicine, 21(6), 522–530. Retrieved from https://doi.org/10.3122/jabfm.2008.06.080042
- Gansevoort, R. T., Matsushita, K., van der Velde, M., Astor, B. C., Woodward, M., Levey, A. S., … Coresh, J. (2011). Lower estimated GFR and higher albuminuria are associated with adverse kidney outcomes: A collaborative meta-analysis of general and high-risk population cohorts. Kidney International, 80(1), 93–104. Retrieved from https://doi.org/10.1038/ki.2010.531
- Greer, R., & Boulware, L. E. (2015). Reducing CKD risks among vulnerable populations in primary care. Advances in Chronic Kidney Disease, 22(1), 74–80. Retrieved from https://doi.org/10.1053/j.ackd.2014.06.003
- Greer, R. C., Powe, N. R., Jaar, B. G., Troll, M. U., & Boulware, L. E. (2011). Effect of primary care physicians’ use of estimated glomerular filtration rate on the timing of subspeciality referral decisions. BMC Nephrology, 12(1), 1–8. Retrieved from https://doi.org/10.1186/1471-2369-12-1
- Institute for Healthcare Improvement. (2016). IHI Initiative: The IHI Triple Aim. Retrieved from https://www.ihi.org/engage/initiatives/TripleAim/Pages/default.aspx
- Kagoma, Y. K., Weir, M. A., Iansavichus, A. V., Hemmelgam, B. R., Akbari, A., Patel, U. D., … Jain, A. K. (2011). Impact of estimated GFR reporting on patients, clinicians, and health-care systems: A systematic review. American Journal of Kidney Disease, 57(4), 592–601. Retrieved from https://doi.org/10.1053/j.ajkd.2010.08.029
- Khan, S., & Amedia, C. A. (2008). Economic burden of chronic kidney disease. Journal of Evaluation in Clinical Practice, 14(3), 422–434. Retrieved from https://doi.org/10.1111/j.1365-2753.2007.00883
- Komenda, P., Ferguson, T. W., Macdonald, K., Rigatto, C., Koolage, C., Manish, M. S., & Tangri, N. (2014). Cost-effectiveness of primary screening for CKD: A systematic review. American Journal of Kidney Disease, 63(5), 789–797. Retrieved from https://doi.org/10.1053/j.ajkd.2013.12.012
- Litvin, C. B., & Ornstein, S. M. (2014). Quality indicators for primary care: An example for chronic kidney disease. Journal of Ambulatory Care Management, 37(2), 171–178. Retrieved from https://doi.org/10.1097/JAC.0000000000000015
- Longino, K., Willis, K., & Vassalotti, J. (2015). National Kidney Foundation proposes new Medicare payment system to improve care for kidney patients. Retrieved from https://www.kidney.org/sites/default/files/20150622%20NKF%20Comments%20on%20Senate%20Chronic%20Care%20Initiative.pdf
- Matsushita, K., Coresh, J., Yingying, S., Chalmers, J., Fox, C., Guallar, E., … Amlov, J. (2015). Estimated glomerular filtration rate and albuminuria for prediction of cardiovascular outcomes: A collaborative meta-analysis of individual participant data. Lancet, 3(7), 514–525. Retrieved from https://doi.org/10.1016/52213-8587(15)00040-6
- National Kidney Foundation (NKF). (2016). About chronic kidney disease. Retrieved from https://www.kidney.org/kidneydisease/aboutckd.cfm
- Ogrinc, G., Davies, L., Goodman, D., Batalden, P., Davidoff, F., & Stevens, D. (2015). SQUIRE 2.0 (Standards for Quality Improvement Reporting Excellence): Revised publication guidelines from a detailed consensus process. Journal of Continuing Education in Nursing, 46(11), 501–507. Retrieved from https://doi.org/10.3928/00220124-20151020-02
- Patwardhan, M., Kawamoto, K., & Matchar, D. (2009). Recommendations for a clinical decision support for th management of individuals with chronic kidney disease. Clinical Journal of the American Society of Nephrology, 4(2), 273–283. Retrieved from https://doi.org/10.2215/CJN.02590508
- Plantinga, L. C., Fink, N. E., Jaar, B. G., Sadler, J. H., Levin, N. W., Coresh, J., … Powe, N. R. (2007). Attainment of clinical performance targets and improvement in clinical outcomes and resource use in hemodialysis care: A prospective cohort study. BMC Health Services Research, 7(5), 1–13. Retrieved from https://doi.org/10.1186/1472-6963-7-5
- Richards, N., Harris, K., Whitfield, M., O'Donoghue, D., Lewis, R., Mansell, M., … Marcelli, D. (2008). Primary care-based disease management of chronic kidney disease (CKD), based on estimated glomerular filtration rate (eGFR) reporting, improves patient outcomes. Nephrology Dialysis Transplantation, 23(2), 549–555. Retrieved from https://doi.org/10.1093/ndt/gfm857
- Sammer, C., Lykens, K., Singh, K., Mains, D., & Lackan, N. (2010). What is patient safety culture? A review of the literature. Journal of Nursing Scholarship, 42(2), 156–165. Retrieved from https://doi.org/10.1111/j.1547-5069.2009.01330
- Schmieder, R. E., Schutte, R., Schumacher, H., Bohm, M., Mancia, G., Weber, M. A., … Yusuf, S. (2014). Mortality and morbidity in relation to changes in albuminuria, glucose status and systolic blood pressure: An analysis of the ONTARGET and TRANSEND studies. Diabetologia, 57(10), 2019–2029. Retrieved from https://doi.org/10.1007/s00125-014-3330-9
- Smart, N. A., & Titus, T. T. (2011). Outcomes of early versus late nephrology referral in chronic kidney disease: A systematic review. American Journal of Medicine, 124(11), 1073–1080. Retrieved from https://doi.org/10.1016/j.amjmed.2011.04.026
- Thavarajah, S., Knicely, D. H., & Choi, M. J. (2016). CKD for primary care practitioners: Can we cut to the chase without too many shortcuts? American Journal of Kidney Diseases, 67(6), 826–829. Retrieved from https://doi.org/10.1053/j.ajkd.2016.02.043
- Thompson-Martin, Y., McCullough, P. A., & Agrawal, V. (2015). Impact of an educational program for advanced practice nurses on knowledge of kidney disease outcomes quality initiative guidelines. Nephrology Nursing Journal, 42(5), 455–460. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/26591270
- Thorp, M., Eastman, L., Smith, D., & Johnson, E. (2006). Managing the burden of chronic kidney disease. Disease Management, 9(2), 115–121. Retrieved from https://doi.org/10.1089/dis.2006.9.116
- U.S. Renal Data System (USRDS). (2015). Annual data report. Retrieved from https://www.usrds.org/reference.aspx
- Vassalotti, J. A., Centor, B., Turner, B. J., Choi, M., & Sequist, T. D. (2016). Practical approach to detection and management of chronic kidney disease for the primary care clinician. American Journal of Medicine, 129(2), 153–162. Retrieved from https://doi.org/10.1016/j.amjmed.2015.08.025
- Vest, B. M., York, T. R., Sand, J., Fox, C. H., & Kahn, L. S. (2015). Chronic kidney disease guideline implementation in primary care: A qualitative report from the TRANSLATE CKD study. Journal of the American Board of Family Medicine, 28(5), 624–631. Retrieved from https://doi.org/10.3122/jabfm.2015.05.150070
- Xu, R., Sun, S., Huo, Y., Yun, L., Huang, S., Li, G., & Yan, S. (2015). Effects of ACEIs versus ARBs on proteinuria or albuminuria in primary hypertension. Medicine, 94(39), 1–12. Retrieved from https://doi.org/10.1097/MD.0000000000001560
