Improvements in Albuminuria Screening Among Individuals with Hypertension Associated with Electronic Health Record Clinical Decision Support Design Changes

Abstract

Background: Albuminuria is associated with increased risk of cardiovascular disease (CVD), heart failure, and progression of chronic kidney disease (CKD). Early detection of albuminuria, done through spot urine albumin creatinine ratio (UACR) testing, enables more accurate risk stratification and timely use of preventative therapies. It remains unacceptably low in the hypertension population.

Methods: We evaluated two EHR-embedded clinical decision support (CDS) strategies at Geisinger Health System in order to increase UACR testing in individuals with hypertension: an OurPractice Advisory (OPA) from Jan 2022 to Aug 2022; and a Health Maintenance Topic (HMT) in the Care Gaps section of Storyboard from Aug 2022 that continues to date. We evaluated UACR rates from 2020 to 2023 in Geisinger primary care and compared to a control group of healthcare systems in the Optum Labs Data Warehouse [OLDW]. Patients were excluded if they had UACR testing in the preceding 3 years, had diabetes or CKD, or were receiving palliative/hospice care.

Results: We included 58,876 individuals in Geisinger (mean age 59.4 years, 49.6% female) and 1,427,754 in OLDW (61.0 years, 49% female). UACR testing in Geisinger (2.97% in 2020; 2.8% in 2021; 9.7% in 2022; 17.5% in 2023) showed significant increase compared to the control health systems (2.08%, 2.26%, 3.35% and 3.40% respectively). Results were consistent after adjusting for age, sex and race.

Conclusion: OPA increased UACR testing ∼3-fold whereas the HMT was associated with further improvements (∼6-fold vs. baseline) among those with hypertension, suggesting an important role for CDS design in closing care gaps.