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

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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

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New CKD Nomenclature

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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)

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CKD TRIP Reports

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CKD HM Protocols

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CKD Risk Assessment Tool

EHR Tools

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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)

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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

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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

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Lessons Learned

Organizational, provider, patient and technical factors all impacted use of CDS for CKD management

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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

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Patient

• Change expectation to give urine for testing• “CKD” diagnosis required education about

CKD• Several practices linked to NKDEP handout to

explain CKD

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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

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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