Improving Evidence-Based Primary Care for Chronic Kidney Disease

DESCRIPTION (provided by applicant): Chronic kidney disease is steadily increasing in prevalence in the United States, causing significant morbidity and mortality. Stage 3 chronic kidney disease is associated with a 5-year all-cause mortality rate of 24.3% and a 5-year need for renal replacement of 1.3%. Stage 4 chronic kidney disease is associated with a 5-year 45.7% mortality rate and a 5-year 19.9% requirement for renal replacement. There is reasonable evidence that specific actions can be implemented by primary care physicians to delay chronic kidney disease progression and reduce mortality; however, chronic kidney disease is under-recognized and under-treated in primary care offices. The availability of computer decision support (CDS) for chronic kidney disease may help promote effective, evidence-based care, but evidence suggests that CDS alone may not be enough to improve quality of care. Studies have shown improvement in diabetes care from a combination of CDS plus practice facilitation. Studies of similar interventions for chronic kidney disease care have not been conducted. This group randomized controlled trial will test the extent to which CDS plus practice facilitation promotes evidence- based care and improves the clinical outcomes of reduced disease progression and mortality in primary care practices. The practice facilitation intervention is based on an effective approach for implementing the Chronic Care Model; it is a combination of CDS plus having practice facilitators work with on-site teams lead by a physician champion. In addition, each practice will be assigned an academic mentor and have routine audit and feedback of key elements of evidence-based chronic kidney disease care. Evaluation will include an intent-to-treat and process analysis between the CDS practices with facilitation versus the CDS-only practices of the clinical outcomes of chronic kidney disease progression and all-cause mortality. A cost- effectiveness analysis will compare the benefit of the intervention of CDS alone against the intervention of CDS plus practice facilitation in relationship to overall cost per quality adjusted years of life. This study will enroll 40 practices associated with the Distributed Ambulatory Research in Therapeutics Network (DARTNet), a federated network of organizations that use electronic health records.