Electronic Health Record-Based Population Health Management Strategy May Improve CKD Care

Manisha Jhamb, MD, MPH

Credit: UPMC

Findings from a pragmatic, cluster-randomized clinical trial are highlighting the potential of a multifaceted electronic health record and population health management strategy for addressing barriers to the implementation of evidence-based chronic kidney disease (CKD) care.¹

Results from Kidney Coordinated Health Management Partnership (Kidney CHAMP) were published in JAMA Internal Medicine and showed that although the intervention did not reduce patients’ risk of CKD progression compared with usual care, it did increase exposure to angiotensin-converting enzyme inhibitors (ACEi)/angiotensin 2 receptor blockers (ARB) over a median follow-up of 17 months.¹

“Despite the null result, we found that the Kidney-CHAMP framework is scalable, provides equitable access and overcomes barriers on the provider, patient and health system levels,” Manisha Jhamb, MD, MPH, associate chief of the renal-electrolyte division in the University of Pittsburgh School of Medicine, said in a press release.²

The Centers for Disease Control and Prevention estimates 37 million adults in the US have CKD, most of whom are undiagnosed. If left untreated, CKD can progress to kidney failure and early cardiovascular disease, underscoring the need for timely and efficient care.³ However, the growing population of patients affected by CKD and the shortage of nephrologists and primary care clinicians to manage these patients has led to gaps in care associated with poor clinical outcomes and high health care costs.¹

To compare the effectiveness of an electronic health record-based population health management intervention versus usual care for reducing CKD progression and improving evidence-based care, investigators conducted a pragmatic, cluster randomized clinical trial across 101 primary care practices in Western Pennsylvania between May 2019 and July 2022. They enrolled patients 18 - 85 years of age with an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73m2 with a high risk of CKD progression and no outpatient nephrology encounter within the previous 12 months. Investigators defined high-risk CKD as an eGFR of 15 - 29 mL/min/1.73m2, 5-year risk of end-stage kidney disease (ESKD) of 4% or greater determined using a validated 4-variable kidney failure risk equation, or based on an internal machine learning–based risk prediction model incorporating rapid decline in eGFR.¹

Primary care practices were randomly assigned in a 1:1 ratio as clusters to intervention or usual care, stratified by their estimated number of eligible patients at baseline by a study biostatistician using a computer-generated software. The multidisciplinary team-based intervention was designed to provide a comprehensive assessment and management plan for primary care practices to help comanage complex patients and included a nephrology electronic consultation, pharmacist-led medication management, and CKD education for patients. The standard care group received CKD care from primary care clinicians as usual.¹

The primary outcome was time to ≥ 40% reduction in eGFR or ESKD, defined as an eGFR of 10 mL/min/1.73m2 or less or the initiation of kidney replacement therapy, including maintenance dialysis or kidney transplant. Secondary outcomes included hypertension control, ACEi/ARB use, and exposure to potentially unsafe medications.¹

Investigators noted the planned recruitment period of 18 months and average follow-up of 24 months was modified due to COVID-19 pandemic-related delays in enrollment, resulting in extension of the recruitment period to 30 months and change in follow-up duration until the primary outcome was achieved or until the end of intervention period on July 31, 2022.¹

Among 101 primary care study practices, investigators screened 18,157 patients and identified 1596 who met all protocol eligibility criteria and provided implied consent. In total, 754 patients received the intervention and 842 received the control.¹

Investigators noted baseline sociodemographic and clinical characteristics of patients and characteristics of primary care practices were similar between trial arms. Among the cohort, the mean age was 74 (Standard deviation [SD], 9) years and the majority of participants were female (58%) and White (91%).¹

Electronic consultations and medication management encounters were completed for 97% of patients, with a mean of 2.3-2.5 encounters per patient. Education sessions were completed for 469 (62.2%) patients. Only 187 (11.7%) patients in the intervention arm and 205 (12.8%) in the control arm were seen by an outpatient nephrologist during the study period.¹

Over a median follow-up of 17 months, there was no significant difference in the rate of primary endpoint by treatment assignment (7.6% intervention vs 8.6% control), even after adjusting for age, sex, race, baseline eGFR, and primary care practice size (Hazard ratio [HR], 0.96; 95% CI, 0.67-1.38; P = .82). Investigators pointed out there was also no significant difference in hypertension control, exposure to unsafe medications, and adverse events between the arms, although ACEi/ARB exposure was 21% more frequent (Rate ratio [RR], 1.21; 95% CI, 1.02-1.43) in the intervention (197 days per year; 95% CI, 175-219) compared with the control (163 days per year; 95% CI, 146-180).¹

Investigators highlighted the impact of several COVID-19–related issues that potentially contributed to null findings in the study. Additionally, they called attention to several possible limitations to their findings, including the use of electronic health record prescription data to determine medical use, limited ability to examine individual effects of each component of the bundled intervention, and the disproportionate number of White study participants.¹

Still, Barabara Kevish, MD, associate vice president of Medicare Medical Services at UPMC Health Plan, explained the program's benefit, saying "The patients love it because they get that specialized care without an extra appointment with a specialist. From a primary care standpoint, it’s a no-brainer – this program isn’t extra work for me and it’s a value-add for my patients.”

References:

1. ^{Jhamb M, Weltman MR, Devaraj SM, et al. Electronic Health Record Population Health Management for Chronic Kidney Disease Care. JAMA Intern Med. doi:10.1001/jamainternmed.2024.0708}
2. ^{University of Pittsburgh. Kidney disease intervention outcomes encouraging, despite null result. EurekAlert! April 15, 2024. Accessed April 15, 2024. https://www.eurekalert.org/news-releases/1041120}
3. ^{US Centers for Disease Control and Prevention. Chronic Kidney Disease Basics. Chronic Kidney Disease Initiative. February 28, 2022. Accessed April 15, 2024. https://www.cdc.gov/kidneydisease/basics.html}