Better Lab-Based Physician Reminders No Guarantee of Improved Kidney Patient Care

Enhanced laboratory-based treatment prompts may improve primary care physicians’ prescribing habits in some situations, but that does not seem to be the case when it comes to prescribing recommended medications for elderly patients with chronic kidney disease (CKD). That was the conclusion of a study in the April Clinical Journal of the American Society of Nephrology.

“KDIGO [Kidney Disease: Improving Global Outcomes] guidelines on the care of patients with CKD will be released this year, and they will recommend a more complicated system of staging for people with the disease,” said lead author Braden Manns, MD, of the University of Calgary and Alberta Kidney Disease Network, in Alberta, Canada. “Our research suggests that the use of more complex laboratory prompts may not improve care or outcomes.”

Lab prompts for patient care

Effective treatments exist for patients with CKD, who are at risk for progression to end stage renal disease (ESRD) and cardiovascular disease. But these patients often do not receive optimal therapy. Perhaps physicians do not recognize earlier stages of the disease or are unaware of the serious complications that can arise as it progresses.

Clinical decision supports, such as laboratory prompts, have been shown to change physician practice in many randomized trials across a wide range of conditions and interventions, although only a handful of studies have noted an improvement in patient outcomes.

No randomized clinical trials have examined whether providing management-based recommendations along with laboratory reports of kidney function, measured as estimated GFR (eGFR) can help improve care for patients with CKD.

To investigate, Manns and his colleagues conducted a cluster randomized trial, which included patients treated at 93 primary care practices in Alberta, Canada, to test the effect of an enhanced eGFR laboratory prompt for patients with CKD managed by primary care physicians who ordered serum creatinine measurements. The enhanced prompt was compared with a standard laboratory prompt.

Care for CKD

During the study, which included 5444 patients 66 or younger with diabetes or proteinuria and available medication data, the researchers assessed the proportion of patients who received an angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB). “Nearly 20 percent of people over the age of 65 have CKD, and primary care physicians care for over 95 percent of these patients, without the involvement of specialists,” Manns said.

The use of ACEi/ARB in the subsequent year was 77.1 percent in the standard group and 76.9 percent in the enhanced prompt groups. The researchers noted no difference in ACEi or ARB use between the standard and enhanced prompt groups when they repeated the analysis and considered only patients who were not using an ACEi or ARB at baseline. Nor did they see any difference when they considered the subgroup of patients with significant proteinuria in whom ACEi or ARB use could be considered standard of care. Also, when they considered the subgroup of 5055 elderly CKD patients with diabetes or proteinuria who had two eGFR measurements that were less than 60 mL/min per 1.73 m2, in whom the diagnosis of CKD was confirmed according to clinical practice guidelines, they again noted no difference in ACEi or ARB use.

The investigators did note a significant difference in patients with severe CKD. In the subgroup of elderly patients with an eGFR of less than 30 mL/min per 1.73 m2, ACEi or ARB use was 13 percent higher in the enhanced prompt group than in the standard prompt group.

“While we were hoping to increase the use of effective medications, we showed no difference in care or outcomes in the overall population,” said Manns. “We did see a suggestion of benefit in the subgroup of patients with more severe kidney failure, perhaps because primary care doctors may have recognized that these patients were at particularly high risk; therefore, doctors may have been more responsive to management suggestions.”

In a secondary analysis of 22,092 patients with CKD aged 18 years and older, the investigators found no difference in the likelihood of a composite clinical outcome (death, ESRD, doubling of serum creatinine, or hospitalization for myocardial infarction, heart failure, or stroke) with or without the enhanced prompt over an average of 2.1 years. Most of these individuals did not have available medication information because drug coverage is provided only for Albertans older than 65 years by the provincial health ministry,

“Automated reminders like this hold the promise of changing prescribing, lab ordering, and other behaviors with relatively little investment of time and money compared with other knowledge translation strategies, said Kaveh Shojania, MD, who was not involved with the work and is the director of the University of Toronto Centre for Patient Safety, in Ontario, Canada. “In practice, though, these reminders often have small effects (or nil effects, as in this case), as we showed in a meta-analysis in the Canadian Medical Association Journal a few years ago.”

The data from this study suggest that enhanced management-based laboratory prompts cannot currently be recommended for routine use in all patients with CKD.

“We often think that all we have to do is publish ‘high-quality clinical practice guidelines’ and the job of improving care and outcomes is done; however, changing care and outcomes is challenging, even when the evidence is strong,” Manns said.

The authors speculated on why the enhanced laboratory prompt was not effective, noting the possibility that no further improvement in primary outcome was possible, given the high baseline use of ACEi and ARB in both groups (approximately 77 percent) or that the enhanced prompt might not have been more useful than an already effective standard prompt. Physicians in the standard prompt group could access further information and management recommendations by visiting a website suggested in the laboratory report.

Also, the enhanced eGFR prompt might have been too complex, or physicians might have been overwhelmed with the number of patients receiving a prompt, the authors said.