Impact of a Primary Care CKD Registry in a US Public Safety-Net Health Care Delivery System: A Pragmatic Randomized Trial

Abstract

<div class="section"> <a class="named-anchor" id="S1"> <!-- named anchor --> </a> <h5 class="section-title" id="d6555928e200">Background</h5> <p id="P1">Many individuals with chronic kidney disease (CKD) do not receive guideline-concordant care. We examined the impact of a team-based primary care CKD registry on clinical measures and processes of care among patients CKD cared for in a public safety-net healthcare delivery system. </p> </div><div class="section"> <a class="named-anchor" id="S2"> <!-- named anchor --> </a> <h5 class="section-title" id="d6555928e205">Study Design</h5> <p id="P2">Pragmatic trial of a CKD registry versus a usual care registry for one year</p> </div><div class="section"> <a class="named-anchor" id="S3"> <!-- named anchor --> </a> <h5 class="section-title" id="d6555928e210">Setting and Participants</h5> <p id="P3">Primary care providers (PCPs) and their patients with CKD in safety-net primary care setting in San Francisco. </p> </div><div class="section"> <a class="named-anchor" id="S4"> <!-- named anchor --> </a> <h5 class="section-title" id="d6555928e215">Intervention</h5> <p id="P4">The CKD registry identified at point of care: all patients with CKD, those with BP &gt;140/90 mmHg, those without ACEi/ARB prescription, and those without albuminuria quantification in the past year. It also provided quarterly feedback pertinent to these metrics to promote CKD patient “outreach”. The usual care registry provided point-of-care cancer screening and immunization data. </p> </div><div class="section"> <a class="named-anchor" id="S5"> <!-- named anchor --> </a> <h5 class="section-title" id="d6555928e220">Outcomes</h5> <p id="P5">Changes in systolic BP at 12 months (primary outcome), proportion of patients with BP control, prescription of ACEi/ARB, quantification of albuminuria, severity of albuminuria and eGFR. </p> </div><div class="section"> <a class="named-anchor" id="S6"> <!-- named anchor --> </a> <h5 class="section-title" id="d6555928e225">Results</h5> <p id="P6">The patient population (n=746) had a mean age of 56.7 +/− 12.1 (SD) years, was 53% female and was diverse (8% non-Hispanic White, 35.7% Black, 24.5% Hispanic, 24.4% Asian). Randomization to the CKD registry (30 PCPs, 285 patients) versus the usual care registry (49 PCPs, 461 patients) was associated with a 2-fold greater odds of ACEi/ARB prescription (adjusted OR, 2.25; 95%CI, 1.45-3.49) and albuminuria quantification (adjusted OR, 2.44; 95% CI, 1.38-4.29) during the one-year study period. Randomization to the CKD registry was not associated with changes in systolic BP, proportion of patients with uncontrolled BP, or degree of albuminuria or eGFR. </p> </div><div class="section"> <a class="named-anchor" id="S7"> <!-- named anchor --> </a> <h5 class="section-title" id="d6555928e230">Limitations</h5> <p id="P7">Potential misclassification of CKD; missing baseline medication data; limited to study of a public safety-net healthcare system </p> </div><div class="section"> <a class="named-anchor" id="S8"> <!-- named anchor --> </a> <h5 class="section-title" id="d6555928e235">Conclusion</h5> <p id="P8">A team-based safety-net primary care CKD registry did not improve BP parameters, but led to greater albuminuria quantification and more ACEi/ARB prescriptions after one year. Adoption of team-based CKD registries may represent an important step in translating evidence into practice for CKD management. </p> </div>