A primary care intervention to promote guideline-based care for patients with the “kidney dysfunction triad” does not lead to reduced rates of hospitalization due to chronic kidney disease (CKD), reports a pragmatic trial in The New England Journal of Medicine.
The cluster-randomized Improving Chronic Disease Management with Pieces (ICD-Pieces) trial evaluated a multidisciplinary intervention to promote guideline-directed therapy for patients with CKD. The intervention included a personalized algorithm, based on electronic health record data, to identify patients with the triad of CKD, type 2 diabetes, and hypertension, as well as practice facilitators who assisted primary care practitioners in implementing evidence-based interventions.
A total of 11,182 patients at 141 clinics in four large health systems were assigned to intervention or usual-care groups. All-cause hospitalization at 1 year was compared between groups, along with secondary outcomes. Patient characteristics were similar between intervention and usual-care groups.
Rates of hospitalization for any cause were not significantly different between groups: 20.7% for patients assigned to the ICD-Pieces intervention and 21.1% in the usual-care group. Secondary outcomes were similar as well, including emergency department visits, hospital readmissions, cardiovascular events, dialysis, and death from any cause.
The ICD-Pieces intervention was associated with a higher rate of acute kidney injury: 12.7% versus 11.3%. Other adverse events were comparable between groups.
Patients with the kidney dysfunction triad are at high risk for cardiovascular events and kidney failure. Although several guideline-directed therapies targeting these patients have been developed, few studies have evaluated the effects on morbidity and mortality.
The new pragmatic trial shows no significant effect of ICD-Pieces implementation on CKD hospitalization rates. “[T]he use of an EHR [electronic health record]-based algorithm and practice facilitators embedded in primary care clinics did not translate into reduced hospitalization at 1 year,” the researchers write. They discuss implications for future clinical trials of multicomponent interventions for patients with multiple chronic diseases [Vazquez MA, et al.; ICD-Pieces Study Group. Pragmatic trial of hospitalization rate in chronic kidney disease. N Engl J Med 2024; 390:1196–1206. doi: 10.1056/NEJMoa2311708].
