Kidney360 · 2025
Improving CKD Screening and Care in Diabetes Using Clinical Decision Support in a Large Health Care System.
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Park Ken J, Tandy Michalah K, Flerchinger Shaun, Glassberg Kathryn J, Chen Frank Y, Albright Eric S, Nakashimada Lisa J
Аннотация
KEY POINTS: Clinical decision support tools in a large health system increased CKD screening in diabetics from 35% to 72%. Clinical decision support tools resulted in mixed results in CKD quality but was associated with increase in sodium-glucose cotransporter 2 inhibitor use.
BACKGROUND: Guidelines recommend screening for CKD in patients with diabetes with annual urinary albumin-creatinine ratio (ACR) and serum creatinine (Scr). However, screening rates were low in Kaiser Permanente Northwest, a large integrated health care system. We implemented a quality improvement project using clinical decision support (CDS) tools to increase ACR and Scr testing. We examined whether increased CKD screening resulted in improvement in CKD quality metrics, specifically angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and sodium-glucose cotransporter 2 inhibitor (SGLT2i) use.
METHODS: In May 2022, we implemented CDS tools to increase ACR/Scr testing consisting of automated laboratory ordering, best practice alerts (BPAs), and automated laboratory reminders to patients through letters, texts, and phone calls in tandem with provider education on best practice recommendations for CKD. A SGLT2i BPA targeting patients with type 2 diabetes with ACR ≥300 mg/g and eGFR ≥30 ml/min was rolled out in June 2022 and expanded to include patients with eGFR ≥60 ml/min regardless of CKD diagnosis in February 2023. Trends were reviewed monthly using statistical process control charts and changes in slope using segmented regression analysis.
RESULTS: After 3 years, ACR/Scr testing conducted within 1 year increased from 35% to 72%. Angiotensin-converting enzyme inhibitor/angiotensin receptor blockers use increased slightly from 74% to 76%, but nephrology comanagement for high-risk CKD patients remained unchanged at 53%. The rate of SGLT2i use steadily increased by 0.6% each month up until 6 months after introduction of the BPA, after which the rate increased to 1.7%. Among patients not comanaged with nephrology, the adjusted rate of increase was 7% higher in the BPA group compared with patients with CKD in the non-BPA group.
CONCLUSIONS: Our study shows that the use of CDS tools improve CKD screening in patients with diabetes but with mixed results in CKD quality metrics.
BACKGROUND: Guidelines recommend screening for CKD in patients with diabetes with annual urinary albumin-creatinine ratio (ACR) and serum creatinine (Scr). However, screening rates were low in Kaiser Permanente Northwest, a large integrated health care system. We implemented a quality improvement project using clinical decision support (CDS) tools to increase ACR and Scr testing. We examined whether increased CKD screening resulted in improvement in CKD quality metrics, specifically angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and sodium-glucose cotransporter 2 inhibitor (SGLT2i) use.
METHODS: In May 2022, we implemented CDS tools to increase ACR/Scr testing consisting of automated laboratory ordering, best practice alerts (BPAs), and automated laboratory reminders to patients through letters, texts, and phone calls in tandem with provider education on best practice recommendations for CKD. A SGLT2i BPA targeting patients with type 2 diabetes with ACR ≥300 mg/g and eGFR ≥30 ml/min was rolled out in June 2022 and expanded to include patients with eGFR ≥60 ml/min regardless of CKD diagnosis in February 2023. Trends were reviewed monthly using statistical process control charts and changes in slope using segmented regression analysis.
RESULTS: After 3 years, ACR/Scr testing conducted within 1 year increased from 35% to 72%. Angiotensin-converting enzyme inhibitor/angiotensin receptor blockers use increased slightly from 74% to 76%, but nephrology comanagement for high-risk CKD patients remained unchanged at 53%. The rate of SGLT2i use steadily increased by 0.6% each month up until 6 months after introduction of the BPA, after which the rate increased to 1.7%. Among patients not comanaged with nephrology, the adjusted rate of increase was 7% higher in the BPA group compared with patients with CKD in the non-BPA group.
CONCLUSIONS: Our study shows that the use of CDS tools improve CKD screening in patients with diabetes but with mixed results in CKD quality metrics.