Personalized therapy does not reduce hospitalization in chronic kidney disease
1. In this randomized controlled trial, algorithmic identification based on electronic health records (EHRs) and practice facilitators did not reduce hospitalization rates among patients with chronic kidney disease (CKD).
2. Among patients with an unknown ASCVD risk score, those deemed statin-eligible by the model were nearly twice as likely to have incident MACE.
Evidence Rating Level: 1 (Excellent)
Study Rundown: CKD, type 2 diabetes, and hypertension (kidney-dysfunction triad [KDT]) are chronic common comorbidities that carry a significant risk of major adverse cardiovascular events, kidney failure, and death. Multidisciplinary, evidence-based therapy has been shown to improve outcomes in CKD patient populations worldwide. Practice facilitators have been instrumental in increasing the implementation of guideline-directed therapies in primary care settings. Nevertheless, the impact of guideline-directed therapy for KDT is unclear. This pragmatic trial assessed the effect of a combined intervention of patient identification algorithms based on EHRs and practice facilitators on the outcomes of patients with KDT. Compared to usual care, the intervention did not significantly alter the hospitalization rates, emergency department visits, cardiovascular events, dialysis, or death in one year. The overall rates of adverse events were also similar between the two groups. The study was limited by a high baseline rate of care uptake, potentially attenuating the intervention’s impact. Nevertheless, its pragmatic design and diverse patient demographic provided generalizable evidence that increased implementation of guideline-direct therapy through EHR algorithm and practice facilitators did not influence hospitalization rates among patients with KDT.
Click here to read the study in NEJM
In-Depth [randomized controlled trial]: The current study was an open-label, cluster-randomized trial to evaluate the impact of a care intervention to increase the implementation of guideline-directed therapy for patients with KDT in the primary care setting. Patients between 18 and 85 years of age with the KDT of CKD, type 2 diabetes, glycated hemoglobin level, glucose-lowering medication), and hypertension were eligible for inclusion. Exclusion criteria included pregnancy, acute kidney injury, rapidly progressive glomerulonephritis, severe and end-stage CKD, and a life expectancy of less than two years. Overall, 141 primary care practices consisting of 11,182 patients were randomized (1:1) to the intervention group or the usual-care group, employing enrollment via waiver of informed consent. The intervention involved algorithmically identifying patients with KDT based on EHR information and having practice facilitators assist primary care providers in implementing guideline-directed therapy. The primary outcome was hospitalization for any cause by one year. The hospitalization rate was 20.7% (95% Confidence Interval [CI], 19.7-21.8) for the intervention group and 21.1 (95% CI, 20.1-22.2) for the usual-care group (difference 0.4 percentage points; 95% CI, -2.0-1.1; p=0.58). Similarly, there was no significant difference in emergency department visits (difference 1.7 percentage points; 95% CI, -0.2-3.3), readmissions (difference 0.4 percentage points; 95% CI, -3.6-4.3), cardiovascular events (difference 0.9 percentage points; 95% CI, -2.3-0.5), dialysis (difference 0.1. percentage points; 95% CI, -0.2-0.4), and death (difference 0.4 percentage points; 95% CI, -0.9-0.2). The rates of adverse events were also comparable between the two groups, aside from acute kidney injury, which occurred at a slightly higher rate in the intervention group (12.7% vs. 11.3%).
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