Chronic Kidney Disease Clinical Decision Support

Clinics are randomly allocated 1:1 through a computer-generated program to either control or
intervention.

Control Clinics. All control clinics will continue to use the basic Electronic Medical Record
(EMR)-linked CDS for cardiovascular (CV) risk factor management. This CDS includes
algorithmically derived identification of high CV risk patients and prioritized treatment
suggestions for lipids, Blood Pressure (BP), glycemic control, weight, tobacco, and aspirin
use based on distance from goal, current medications, labs, allergies, and safety
considerations. The basic CDS does not include information specific to CKD care.

Intervention Clinics. The CKD-CDS intervention provides updated clinical recommendations at
any primary care visit for patients meeting inclusion and exclusion criteria. This presents
patients and their primary care providers (PCPs) multiple opportunities to consider an
evolving array of timely, evidence-based treatment options to improve CKD care. The CKD-CDS
intervention is rooted in a series of antecedent studies that developed more limited but
successful forms of CDS. From an operational point of view, implementing CKD-CDS at
intervention clinics requires a series of 4 distinct steps that occur at every encounter:

Step 1: Data exchange and evaluation: The EMR securely exchanges data with the Web Service at
every encounter of patients aged 18-75 triggered by BP entry.

Step 2: Recognition of CKD and presence of care deficits: Patients with stage 3-4 CKD are
automatically identified by the Web Service and evaluated using algorithms maintained in the
Web service for identification of CKD and for the 5 emphasized care gaps (identification of
CKD, BP control, glucose control, Angiotensin converting enzyme inhibitor (ACEI)/Angiotensin
receptor blocker (ARB) use if appropriate, and nephrology consultation if appropriate). If
the patient has a care gap, the rooming staff receives an immediate best practice advisory
(BPA) prompt to print CDS materials for the patient and the provider to review and use for
shared decision making. Using a sequence of steps successfully implemented in previous
studies, the rooming staff will print the materials and give the lay version to the patient
to review while waiting for the provider. A professional version is left on the door for the
provider to review before entering the exam room. This approach has been well-liked by our
providers to help them be prepared and to engage patients in their care needs before the
clinician-patient interaction. PCPs can also optionally view an electronic version of the CDS
materials. The CDS can be viewed in real time for any patient by clicking on a button
programmed in the EMR encounter display.

Step 3: Use of CKD-CDS recommendations as shared decision-making tools: The participating
providers and all rooming staff in the intervention clinics will be trained in the use of the
PCP (professional) and patient (low-literacy) versions of the CKD-CDS. For this study, the
CDS tool will be adapted to emphasize CKD and, for each identified deficit in CKD care, the
CKD-CDS will display patient-specific recommendations consistent with then-current national
CKD clinical guidelines; for example: (a) recognize CKD and ask the PCP to enter a CKD
diagnosis on the problem list if indicated, and/or (b) specific considerations for how to
modify BP control, glucose control, or ACEI/ARB therapy, and/or (c) refer certain patients to
nephrology when referral criteria are met. The PCP assesses patient preference for any of the
CKD-related treatment options. If the patient wants to act on 1 or more, the PCP can address
it then or schedule a subsequent visit for that purpose. If the patient is not interested in
any option, no further action is needed at that day's visit. The decision support provided to
the PCP is very specific and, if pharmacotherapy is indicated, decision support specifies
either initiation or titration of specific drugs based on the drugs/doses the patient is
currently taking, distance from goal, and other clinical considerations outlined above. The
patient version of the CKD-CDS uses symbols to provide easy patient recognition of priority
clinical areas and then suggests potential treatment options they can discuss with their
provider. Presenting key CKD care recommendations when indicated (all of which are evidence
based and capable of improving CKD care) allows the patient freedom to select his or her
preferred treatment option from among several potentially beneficial treatment options.
Because patient readiness to take health-related actions varies across specific actions,
offering several options improves the chance that a given patient may be interested in
addressing at least 1 of the evidence-based options presented. Moreover, patient readiness to
act is a key predictor of subsequent adherence and success of treatment, as we have
previously shown in this patient population. It is important to realize that the printed page
the patient receives frames the discussion to a set of prioritized evidence-based treatment
options with likely benefit to the patient.

Step 4. Take action based on the decisions made: After discussing with the patient, the
provider can then go ahead and order the recommendations suggested by the CDS such as labs,
medication, e-consults with nephrology, and referrals to specialists. All actions taken are
also based on the provider's clinical judgement.

Inclusion Criteria:

1. Age 18 to 75 years, inclusive. The evidence-based guidelines on which the CDS
intervention is based are not applicable outside this age range.

2. Have confirmed CKD based on 2 or more eGFR values <60 cc/min/1.73m2, including the
most recent eGFR value and a previous eGFR at least one week prior

3. Have a CKD care component suboptimally managed as defined by one or more of the
following:

1. Have two or more BP values from separate encounter dates of >=130/80 including
the most recent BP to the index visit

2. Have an individualized A1C over goal as determined by CDS algorithm criteria of
most recent glycated hemoglobin (A1C) > 7% OR > 8% if any of the following
conditions are identified: cardiovascular disease (CVD) or calculated 10-yr
atherosclerotic cardiovascular disease (ASCVD) risk >30%, cancer, hypoglycemia,
cognitive impairment, on 2 or more glycemia medications with insulin, or on 3 or
more non-insulin glycemia medications

3. Have most recent eGFR 30-59 with hypertension identified or ACR > 30 mg/g and not
on an ACEI or ARB

4. Have non-steroidal anti-inflammatory drug (NSAID) other than aspirin on the
active medication list

5. Have a eGFR 15-29 or ACR > 300 mg/g without a nephrology visit in the last 12
months

Exclusion Criteria:

An individual who meets any of the following criteria will be excluded from receiving the

CKD-CDS:

1. Patients enrolled in hospice,

2. Patients with active cancer or undergoing chemotherapy

3. Patients with pregnancy in the last year

4. Patients with end stage renal disease

Individuals who meet all inclusion and exclusion criteria at an index visit and have at
least one post-index visit in the following 12 months will be included in the primary
analyses.