PPRNet Lessons Learned from CKD-TRIP Chronic Kidney Disease: Translating Research into Practice Cara...
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Transcript of PPRNet Lessons Learned from CKD-TRIP Chronic Kidney Disease: Translating Research into Practice Cara...
PPRNet
Lessons Learned from CKD-TRIPChronic Kidney Disease: Translating
Research into Practice
Cara Litvin MD, MS
Funded by the Agency for Healthcare Research and Quality
1K08HS01898407/01/2011 – 06/30/2015
©PPRNet 2015
Agenda
• Briefly describe the CKD-TRIP project• Present preliminary results• Described lessons learned from
project
©PPRNet 2015
Updated CKD Clinical Practice Guidelines
• Emphasis on early identification of patients with CKD
• Classification by cause, eGFR and albuminuria (urine albumin to creatinine ratio)
• BP goal based on level of albuminuria
• Use of ACEI/ARB for albuminuria
©PPRNet 2015
New CKD Nomenclature
©PPRNet 2015
CKD-TRIP Project Goals
Demonstration project to:• Identify a set of primary care CKD quality
measures• Develop clinical decision support tools that can
be used to identify and enhance care of CKD patients
• Implement and assess these tools in 11 PPRNet practices (compared to passive control group)
©PPRNet 2015
CKD TRIP Reports
©PPRNet 2015
CKD HM Protocols
©PPRNet 2015
CKD Risk Assessment Tool
EHR Tools
©PPRNet 2015
Results
Significantly improved:• Screening for albuminuria in patients at risk
for CKD (median increase 25% over 24 mos)• Testing for albuminuria in patients with CKD
(median increase 30% over 24 mos)Trends toward significance:• Hemoglobin monitoring in pts with Stage 3b-
5CKD (median increase 7% over 24 mos)
©PPRNet 2015
Results
No significant changes in:• eGFR monitoring for pts at risk for CKD or pts
with CKD• BP monitoring every 6 months in pts with CKD• BP control in pts with CKD• ACEI for pts with CKD• LDL monitoring in pts with CKD• NSAID use in pts with CKD
©PPRNet 2015
Results
• 32% increase in patients meeting criteria for CKD per practice over 24 months
• 100% increase in patients found to have urine albumin to cr ratio > 300
©PPRNet 2015
Lessons Learned
Organizational, provider, patient and technical factors all impacted use of CDS for CKD management
©PPRNet 2015
Organizational Factors
• Practice-wide prioritizing identification of CKD patients led to improvements
• Many practices used in-office testing for urine albumin (Clinitek machine)
• Standing orders were used by half of practices(empowered nurse, MA or even lab tech to obtain appropriate test)
• Patient registry used by a few practices for outreach by staff
• Staff turnover reported to be a barrier in 2 practices
©PPRNet 2015
Provider Factors
• Identifying patients with CKD motivated further improvement
• Some disagreement about guidelines• Some patients co-managed by nephrologists• Concerns about data validity (e.g. BP better at
home)• Despite HM and prompts, reported
forgetfulness to order tests
©PPRNet 2015
Patient
• Change expectation to give urine for testing• “CKD” diagnosis required education about
CKD• Several practices linked to NKDEP handout to
explain CKD
©PPRNet 2015
Technical Factors
• Tools reported to help focus attention on CKD• Sometimes risk assessment tool did not load
or bring in all pertinent labs• Reports and tools did not capture labs ordered
by specialists• Use of registry required re-identifying patients
©PPRNet 2015
Conclusion
CDS tools may help improve identification of patients with CKD…
But successful adoption and use requires attention to many other organization, provider, patient and technical factors