A cluster randomized trial of an enhanced eGFR prompt in chronic kidney disease

Abstract

Background and objectives: Despite reporting estimated GFR (eGFR), use of evidence-based interventions in CKD remains suboptimal. This study sought to determine the effect of an enhanced eGFR laboratory prompt containing specific management recommendations, compared with standard eGFR reporting in CKD.

Design, setting, participants, & measurements: A cluster randomized trial of a standard or enhanced eGFR laboratory prompt was performed in 93 primary care practices in Alberta, Canada. Although all adult patients with CKD (eGFR <60 ml/min per 1.73 m(2)) were included, medication data were only available for elderly patients (aged ≥66 years). The primary outcome, the proportion of patients with diabetes or proteinuria receiving an angiotensin converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB), was assessed in elderly CKD patients.

Results: There were 5444 elderly CKD patients with diabetes or proteinuria who were eligible for primary outcome assessment, irrespective of baseline ACEi/ARB use. ACEi/ARB use in the subsequent year was 77.1% and 76.9% in the standard and enhanced prompt groups, respectively. In the subgroup of elderly patients with an eGFR <30 ml/min per 1.73 m(2), ACEi/ARB use was higher in the enhanced prompt group. Among 22,092 CKD patients, there was no difference in the likelihood of a composite clinical outcome (death, ESRD, doubling of serum creatinine, or hospitalization for myocardial infarction, heart failure, or stroke) over a median of 2.1 years.

Conclusions: In elderly patients with CKD and an indication for ACEi/ARB, an enhanced laboratory prompt did not increase use of these medications.

Figure 1.

Selection of clusters.

Figure 2.

Secondary outcomes among all CKD patients receiving standard and enhanced prompts. ¹Percentages represent patients with outcome out of the number of patients in the subgroup of interest. ²Defined as use of a cholesterol-lowering drug (defined as any statin, fibrate, or ezetimibe prescription). RR, relative risk; 95% CI, 95% confidence interval; eGFR, estimated GFR.

Figure 3.

Proportion of CKD patients with a subsequent measurement of urine albumin, lipids, and hemoglobin A1C (in patients with diabetes) among patients who had no measure in the prior 6 months. ¹Percentages represent patients with outcome out of the number of patients in the subgroup of interest. RR, relative risk; 95% CI, 95% confidence interval; eGFR, estimated GFR.

Figure 4.

The occurrence of a clinically relevant composite endpoint¹ among CKD patients receiving standard and enhanced prompts. ¹Defined as death, ESRD, doubling of serum creatinine, and hospitalization for myocardial infarction, heart failure, or stroke. ²Percentages represent patients with outcome out of the number of patients in the subgroup of interest. RR, relative risk; eGFR, estimated GFR; 95% CI, 95% confidence interval.