Physician reminders don't improve care for kidney disease patients

Laboratory-based treatment reminders meant to improve physicians' prescribing habits for patients with chronic kidney disease (CKD) may not be effective, according to a study appearing in an upcoming issue of the Clinical Journal of the American Society Nephrology (CJASN). The findings indicate that adding information on how to treat patients with CKD to kidney laboratory test results does not provide any benefits.

Nearly 20% of people over the age of 65 years have CKD, and primary care physicians care for the vast majority of these patients without input from kidney specialists.

Treatment aids for doctors – such as prompts or reminders that suggest what to prescribe when a test result comes back – could improve care for people with various health problems. Braden Manns, MD (University of Calgary and Alberta Kidney Disease Network, in Alberta, Canada) and his colleagues looked to see if adding information on how to treat CKD patients to kidney test results might improve the care provided by primary care physicians.

The study included 22,092 patients with CKD who were treated at 93 primary care practices in Alberta, Canada. Of these, 5,444 patients were older than 65 years of age and had medication data available. Some patients' physicians received a standard laboratory prompt with kidney test results while others received an enhanced prompt that recommended that they prescribe an angiotensin converting enzyme inhibitor (ACEi) or angiotensin receptor blocker, which are recommended for CKD patients by clinical practice guidelines.

Among the major findings one year after the study began:

• Overall, ACEi/ARB use was 77.1% and 76.9% in the standard and enhanced prompt groups, respectively, suggesting no difference in care.
• In patients with severe kidney failure, ACEi/ARB use was higher in the enhanced prompt group.

"While we were hoping to increase the use of effective medications, we showed no difference in care or outcomes in the overall population," said Dr. Manns. "We did see a suggestion of benefit in the subgroup of patients with more severe kidney failure, perhaps because primary care doctors may have recognized that these patients were at particularly high risk; therefore doctors may have been more responsive to management suggestions."

In a broader analysis of the entire patient group, including those for whom medication information was not available, the investigators found that use of the enhanced laboratory prompt did not improve patients' health outcomes compared with the standard prompt.

"Our research suggests that the use of more complex laboratory prompts may not improve care or outcomes," said Dr. Manns. These findings are particularly relevant because new guidelines on caring for CKD patients are expected this year.