1. PPRNet Lessons Learned from CKD-TRIP Chronic Kidney Disease: Translating Research into Practice Cara Litvin MD, MS Funded by the Agency for Healthcare Research and Quality 1K08HS018984 07/01/2011 – 06/30/2015

2. Agenda Briefly describe the CKD-TRIP project Present preliminary results Described lessons learned from project ©PPRNet 2015

3. Updated CKD Clinical Practice Guidelines Emphasis on early identification of patients with CKD Classification by cause, eGFR and albuminuria (urine albumin to creatinine ratio) BP goal based on level of albuminuria Use of ACEI/ARB for albuminuria ©PPRNet 2015

4. New CKD Nomenclature ©PPRNet 2015

5. CKD-TRIP Project Goals Demonstration project to: Identify a set of primary care CKD quality measures Develop clinical decision support tools that can be used to identify and enhance care of CKD patients Implement and assess these tools in 11 PPRNet practices (compared to passive control group) ©PPRNet 2015

6. CKD TRIP Reports ©PPRNet 2015

7. CKD HM Protocols ©PPRNet 2015

8. CKD Risk Assessment Tool ©PPRNet 2015 EHR Tools

9. Results Significantly improved: Screening for albuminuria in patients at risk for CKD (median increase 25% over 24 mos) Testing for albuminuria in patients with CKD (median increase 30% over 24 mos) Trends toward significance: Hemoglobin monitoring in pts with Stage 3b- 5CKD (median increase 7% over 24 mos) ©PPRNet 2015

10. Results No significant changes in: eGFR monitoring for pts at risk for CKD or pts with CKD BP monitoring every 6 months in pts with CKD BP control in pts with CKD ACEI for pts with CKD LDL monitoring in pts with CKD NSAID use in pts with CKD ©PPRNet 2015

11. Results 32% increase in patients meeting criteria for CKD per practice over 24 months 100% increase in patients found to have urine albumin to cr ratio > 300 ©PPRNet 2015

12. Lessons Learned Organizational, provider, patient and technical factors all impacted use of CDS for CKD management ©PPRNet 2015

13. Organizational Factors Practice-wide prioritizing identification of CKD patients led to improvements Many practices used in-office testing for urine albumin (Clinitek machine) Standing orders were used by half of practices (empowered nurse, MA or even lab tech to obtain appropriate test) Patient registry used by a few practices for outreach by staff Staff turnover reported to be a barrier in 2 practices ©PPRNet 2015

14. Provider Factors Identifying patients with CKD motivated further improvement Some disagreement about guidelines Some patients co-managed by nephrologists Concerns about data validity (e.g. BP better at home) Despite HM and prompts, reported forgetfulness to order tests ©PPRNet 2015

15. Patient Change expectation to give urine for testing “CKD” diagnosis required education about CKD Several practices linked to NKDEP handout to explain CKD ©PPRNet 2015

16. Technical Factors Tools reported to help focus attention on CKD Sometimes risk assessment tool did not load or bring in all pertinent labs Reports and tools did not capture labs ordered by specialists Use of registry required re-identifying patients ©PPRNet 2015

17. Conclusion CDS tools may help improve identification of patients with CKD… But successful adoption and use requires attention to many other organization, provider, patient and technical factors ©PPRNet 2015