Screening for CKD To Improve Processes of Care among Nondiabetic Veterans with Hypertension: A Pragmatic Cluster-Randomized Trial.

BACKGROUND AND OBJECTIVES: We conducted a pilot, pragmatic, cluster-randomized trial to evaluate feasibility and preliminary effectiveness of screening for CKD using a triple-marker approach (creatinine, cystatin C, and albumin/creatinine ratio), followed by education and guidance, to improve care of hypertensive veterans in primary care. We used the electronic health record for identification, enrollment, intervention delivery, and outcome ascertainment. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We randomized 1819 veterans without diabetes but with hypertension (41 clusters) into three arms: (1) CKD screening followed by patient and provider education; (2) screening, education, plus pharmacist comanagement; or (3) usual care. The primary clinical outcome was BP change over 1 year. Implementation and process measures included proportion screened; CKD detection rate; and total and new use of renin-angiotensin system inhibitors, nonsteroidal anti-inflammatory drugs, and diuretics. RESULTS: Median age was 68 years, 55% were white, 1658 (91%) had a prior creatinine measure, but only 172 (9%) had prior urine albumin/creatinine ratio, and 83 (5%) had a prior cystatin C measure. Among those in the intervention, 527 of 1215 (43%) were identified with upcoming appointments to have CKD screening. Of these, 367 (69%) completed testing. Among those tested, 77 (21%) persons had newly diagnosed CKD. After 1 year, change in systolic BP was -1 mm Hg (interquartile range, -11 to 11) in usual care, -2 mm Hg (-11 to 11) in the screen-educate arm, and -2 mm Hg (-13 to 10) in the screen-educate plus pharmacist arm; P=0.49. There were no significant differences in secondary outcomes in intention-to-treat analyses. In as-treated analyses, higher proportions of participants in the intervention arms initiated a renin-angiotensin system inhibitor (15% and 12% versus 7% in usual care, P=0.01) or diuretic (9% and 12% versus 4%, P=0.03). CONCLUSIONS: The pragmatic design made identification, enrollment, and intervention delivery highly efficient. The limited ability to identify appointments resulted in inadequate between-arm differences in CKD testing rates to determine whether screening improves clinical outcomes.

Validating laboratory defined chronic kidney disease in the electronic health record for patients in primary care.

BACKGROUND: Electronic health record (EHR) data is increasingly used to identify patients with chronic kidney disease (CKD). EHR queries used to capture CKD status, identify comorbid conditions, measure awareness by providers, and track adherence to guideline-concordant processes of care have not been validated. METHODS: We extracted EHR data for primary-care patients with two eGFRcreat 15-59 mL/min/1.73 m^2 at least 90 days apart. Two nephrologists manually reviewed a random sample of 50 charts to determine CKD status, associated comorbidities, and physician awareness of CKD. We also assessed the documentation of a CKD diagnosis with guideline-driven care. RESULTS: Complete data were available on 1767 patients with query-defined CKD of whom 822 (47%) had a CKD diagnosis in their chart. Manual chart review confirmed the CKD diagnosis in 34 or 50 (68%) patients. Agreement between the reviewers and the EHR diagnoses on the presence of comorbidities was good (κ > 0.70, p < 0.05), except for congestive heart failure, (κ = 0.45, p < 0.05). Reviewers felt the providers were aware of CKD in 23 of 34 (68%) of the confirmed CKD cases. A CKD diagnosis was associated with higher odds of guideline-driven care including CKD-specific laboratory tests and prescriptions for statins. After adjustment, CKD diagnosis documentation was not significantly associated with ACE/ARB prescription. CONCLUSIONS: Identifying CKD status by historical eGFRs overestimates disease prevalence. A CKD diagnosis in the patient chart was a reasonable surrogate for provider awareness of disease status, but CKD awareness remains relatively low. CKD in the patient chart was associated with higher rates of albuminuria testing and use of statins, but not use of ACE/ARB.

Implementation of a pragmatic randomized trial of screening for chronic kidney disease to improve care among non-diabetic hypertensive veterans.

BACKGROUND: Whether screening for chronic kidney disease (CKD) can improve the care of persons at high risk for complications remains uncertain. We describe the design and early implementation experience of a pilot, cluster-randomized pragmatic trial to evaluate the feasibility, implementation, and effectiveness of a "triple marker" CKD screening program (creatinine, cystatin C and albumin to creatinine ratio) for improving care among hypertensive veterans seen in primary care at one Veterans Administration Hospital. METHODS/DESIGN: Non-diabetic hypertensive veterans age 18-80 without known CKD were randomized in clusters determined by primary care provider (unit of randomization) into three arms. Usual care will be compared with two incrementally intensified treatment strategies: (1) screen for CKD followed by patient and provider education or (2) screen-educate plus a clinical pharmacist-led CKD and BP management program. The primary clinical outcome is systolic blood pressure (BP) change from baseline. Secondary clinical outcome is BP control. The primary process outcomes is triple marker screening (across three arms), and secondary process outcomes include use of inhibitors of the renin-angiotensin system (ACE/ARB) overall and in persons with albuminuria, CKD recognition by PCP, use of non-steroidal anti-inflammatory drugs (NSAIDs) and NSAID education by PCP. The design uses the Veterans Health Administration electronic health record (EHR) to identify participants, deliver the interventions and ascertain study outcomes. Assessment of the program implementation will use the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Study duration is 12 months. RESULTS: A total of 1,819 patients have been randomized within 41 provider clusters. The median age (interquartile range) is 68 years (61-72), and 99% of participants are male. Approximately 16% are Black, and 5% Hispanic. In the first 6 months of the trial, 434 triple marker screening tests have been ordered, and 217(50%) have been tested. A total of 48 new CKD cases have been identified among those tested, for a preliminary yield of 22%. CONCLUSION: We have successfully implemented a pragmatic protocol that uses the EHR to identify and characterize eligible participants, deliver the intervention, and ascertain study outcomes with high rates of participation by providers and patients. Results from this study can guide design of pragmatic trials in the field of CKD. TRIAL REGISTRATION: NCT01978951 ; Date or Registration: 1/17/2014.

A longitudinal study of overweight, elevated blood pressure, and acanthosis nigricans among low-income middle school students.

This longitudinal study examined the rates of overweight, elevated blood pressure, acanthosis nigricans, and their associated factors in third through fifth grade students over 4 years. Participants consisted of 279 students who participated in health screenings in 2002 and 2006. Hispanic students had significantly higher rates of overweight and acanthosis nigricans compared to White students. There was a sharp increase in elevated blood pressure from 2002 to 2006 among obese children. While 20% of the matched obese students were above the 90th percentile in 2002, 82% of the same students were above the 90th percentile in 2006. After controlling for sex, ethnicity, and grade, preadolescent obesity in 2002 continued to be a significant factor associated with elevated blood pressure and acanthosis nigricans in 2006. These findings demonstrate that prevention and treatment of obesity during preadolescence is critical for the prevention of elevated high blood pressure in early adolescence.