Study: PCPs do not often use clinical decision support when diagnosing patients with CKD
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Primary care physicians did not use clinical decision support often when diagnosing patients with chronic kidney disease, according to data published in Kidney Medicine.
“Our objective was to determine whether clinical decision support could have a positive impact on stage-appropriate monitoring and referral. There were three main goals of the clinical trial,” Lipika Samal, MD, MPH, from the division of general internal medicine and primary care at Brigham and Women’s Hospital in Boston, and colleagues wrote. “The first was to determine whether non-interruptive point-of-care clinical decision support would be noticed and acted upon by primary care physicians. The second was to determine whether recommendations regarding laboratory testing would be followed. The third was to determine whether automatic calculation of the 5-year kidney failure risk equation value would increase referral to nephrology in high-risk patients.”
In a block-randomized, pragmatic clinical trial, researchers evaluated 5,590 adults with stages 3 to 5 CKD from 10 primary care clinics in the greater Boston area between Dec. 4, 2015, and Dec. 3, 2016. The trial included a 6-month follow-up period.
Researchers randomized patients within each primary care physician panel. Patients in the control arm (n=2,796) received usual care, whereas those in the intervention arm (n=2,794) could be treated with point-of-care non-interruptive clinical decision support. The intervention provided a 5-year kidney failure risk equation in addition to recommendations for stage-appropriate monitoring and referral to nephrology. Physicians had the option to click the link on the electronic health record screen to see the clinical decision support.
Samal and colleagues wrote, “The linked webpage included the following: 1) the stage of CKD based on the eGFR and urinary albumin-creatinine ratio; 2) the kidney failure risk equation estimate; 3) clinical decision support recommendations to order laboratory tests and/or refer the patient to nephrology if risk is [greater than]10%; and 4) the laboratory data used in the calculation of the risk estimate, along with data entry fields to allow the primary care physician to update the values and recalculate the risk estimate.”
Researchers considered the primary outcome as urine and serum laboratory monitoring test results 6 months after a patient’s initial primary care visit. However, these results were only considered among patients who did not undergo the recommended monitoring test in the previous 12 months.
Among the 569,533 continuity of care documents the clinical decision support application requested and processed, researchers found 41,842 led to a diagnosis of stage 3, 4 or 5 CKD. Analyses revealed the link to the clinical decision support application was clicked 122 times of 2,794 available cases by 57 physicians. Only 14 physicians clicked the link more than once, with the most a user click being 20 times. While researchers did not identify a correlation between the clinical decision support intervention and the primary outcome, they did observe a higher rate of nephrology referral in the control arm.
“Our study found no effect of the intervention on stage-appropriate monitoring. The only statistically significant finding was that, within the subgroup of patients with a kidney failure risk equation risk of greater than 10%, patients in the control arm had a higher proportion of nephrology referral than patients in the intervention arm, an absolute difference of 43 patients,” Samal and colleagues wrote. They added, “In conclusion, this pragmatic randomized controlled trial of non-interruptive clinical decision support delivering the kidney failure risk equation risk to primary care physicians failed to show an effect on stage-appropriate monitoring and referral. Future efforts should include multicomponent interventions, community-based screening of high-risk populations and population health management of patients at a high risk of kidney failure.”
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