A Risk Based Approach to Improving Chronic Kidney Disease Management

Specific Aim 1 We will develop software to calculate the estimated glomerular filtration rates for all patients presenting to primary care physicians randomized to the intervention arm, and identify patients with an estimated glomerular filtration rates in the range of 30 to 59. We will create three electronic alerts that intervention clinicians will receive upon accessing the patient chart based on whether the patient is high risk or low risk. These alerts will focus on recommending overdue laboratory tests (urine protein, blood cholesterol, etc), as well as recommending guideline appropriate medications (ACE inhibitors), and nephrology referral when appropriate.

We will provide self management support materials to patients of primary care physicians randomized to the intervention arm. We will rely on primary care physicians to enroll patients by first recommending referral via the electronic alerts. On a monthly basis, we will identify patient visits during which an alert fired and no referral was placed. We will distribute a list of these patients to each physician via inter-office mail at least every other month. The mailing will ask physicians to return the list indicating which patients should be enrolled in the program, and our project manager will place the referrals. For non-responding physicians, we will follow up with a reminder email. The patient mailings will include recent clinical results and guideline-recommended targets, encouraging patients to become more proactive in the management of their kidney disease. Once a patient is enrolled in the program, they will receive similar mailings with updated personalized data and recommendations every 3 months.

Electronic referrals placed by primary care physicians for management of chronic kidney disease will first be routed to the renal nurse, who will then initiate contact with the patient. A total of two telephone calls followed by a letter will be made to contact the patient. The nephrology visits will occur per standard clinical operations, including evaluation by an attending nephrologist, as well as educational sessions with the renal nurse and nutritionist. We will create new template notes within the electronic record for use by the nephrologists to communicate clinical care recommendations back to the primary care physicians.

Prior to starting the intervention, the study team will travel to each of the 14 health centers to conduct orientation sessions with the primary care physicians. These sessions will provide general information regarding the goals and scope of the upcoming intervention, including demonstrations of the electronic alerts and the self management support outreach program. A similar overview will also be provided to the HVMA Division of Nephrology.

We will randomize approximately 170 physicians into the intervention and control groups. Physicians in the intervention group will receive patient-specific alerts at the time of office visits for patients with Stage 3 kidney disease. Physicians in the control group will not receive active alerts.