Development of a feasible and portable electronic flag for near-real-time identification of renal replacement therapy in the Veterans Health Administration.

BACKGROUND

Chronic kidney disease (CKD) is prevalent among US Veterans. Identifying patients undergoing dialysis in real-time is crucial for implementing patient safety measures, including stewardship interventions, such as medication dosing adjustments. Limited feasible and accurate tools exist for near-real-time identification. This study aimed to develop a renal replacement therapy (RRT) flag using structured data in the Veterans Health Administration (VHA) electronic health record (EHR).

METHODS

Data from Veterans who underwent cardiovascular implantable electronic device (CIED) procedures (9/2015-12/2019) were linked to US Renal Data Systems (USRDS) data. Potential identifiers included outpatient hemodialysis procedure records, community care hemodialysis consults, ICD-10 diagnoses, and serum creatinine (SCr) >4 mg/dL. USRDS served as the comparison standard, and sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Logistic regression determined the area under the curve (AUC).

RESULTS

Among 37,706 CIED procedures on 34,994 Veterans, 967 patients (2.6%) were identified by USRDS as ever receiving RRT (hemodialysis and peritoneal dialysis or transplant), with 520 (1.4%) actively receiving RRT at the time of CIED. The RRT flag, combining ≥4 outpatient procedures in the prior 30 days, ≥1 consult in the prior year, and/or SCr >4 mg/dL, achieved an AUC of 0.976 (95% CI: 0.97-0.98), with high sensitivity (0.96; 95% CI: 0.94-0.97) and specificity (0.99; 95% CI: 0.99-1.00). The PPV was 0.70 (95% CI: 0.67-0.74). Performance was slightly lower when consults were replaced with ICD codes.

CONCLUSIONS

We developed an accurate electronic flag using structured data to identify active RRT within VHA among Veterans undergoing invasive procedures, supporting patient safety and care adjustments. This flag addresses a crucial patient safety gap and supports expansion of stewardship efforts.