A team-based CKD registry improves some clinical measures and care processes for patients in a safety-net primary care setting, reports a trial in the American Journal of Kidney Diseases.
Many patients with CKD do not receive guideline-based care shown to improve clinical outcomes. Disease registries embedded in electronic health records can improve quality of care for some chronic diseases.
The pragmatic trial evaluated in the AJKD study looked at an electronic CKD registry designed to identify patients with CKD and provide primary care team members with data relevant to their care. The study included 746 patients at a public safety-net care setting in San Francisco that had a high burden of hypertension and CKD. Patients and providers were assigned to 1 year of the CKD registry or a usual-care registry.
The primary care CKD registry targeted all patients with CKD, those with blood pressure over 140/90 mm Hg, those without an ACEI/ARB prescription, and those without an albuminuria measurement in the past year. In addition to sending alerts to the primary care team, the registry provided quarterly feedback to promote outreach to patients with CKD. Change in systolic BP at 1 year was assessed, along with BP control, ACEI/ARB prescribing, measurement and severity of albuminuria, and eGFR.
The patients’ mean age was about 57 years; 53% were women. About 36% were black, 25% Hispanic, and 24% Asian. Based on albuminuria and/or eGFR measurements, 41.6% of patients had stage 1 or 2 CKD, 38.6% had stage 3a and 15% stage 3b CKD, and 4.8% had stage 4 disease. Thirty-eight percent of patients had a baseline albuminuria measurement; in this group, the average albumin–creatinine ratio was 421 mg/g. About 20% of patients had glycated hemoglobin greater than 6.5%, while 36% had uncontrolled BP. Overall, 30 primary care patients and 285 other patients were assigned to the CKD registry. Forty-nine primary care patients and 461 other patients were assigned to the usual care registry.
At 1 year, there was no significant difference in change in systolic BP (the primary outcome) between groups. There was also no difference in the percentage of patients with uncontrolled BP. Patients assigned to the CKD registry were twice as likely to have an ACEI/ARB prescription, adjusted odds ratio (OR) 2.25; and to undergo albuminuria measurement, OR 2.44. There was no significant difference in the degree of albuminuria or eGFR.
The CKD registry evaluated in this trial focused on behavior change throughout the healthcare team, not just for individual physicians.
While it didn’t improve blood pressure, the primary care CKD registry increased rates of albuminuria measurement and ACEI/ARB prescribing in a public safety-net care setting. “Adoption of team-based CKD registries may represent an important step in translating evidence into practice for CKD management,” the researchers write [Tuot DS, et al. Impact of a primary care CKD registry in a US public safety-net health care delivery system: a pragmatic randomized trial. Am J Kidney Dis 2018; 72:168–173].