EHR Alerts Trigger Primary Care Clinics to Improve Hypertension Care in CKD

A computerized clinical decision support (CDS) tool for primary care helped lower blood pressure (BP) in patients with chronic kidney disease (CKD) and uncontrolled hypertension, a cluster-randomized trial found.

When primary care practitioners (PCPs) were randomized to a CDS system instead of usual care, there was a modestly better reduction in average systolic BP among patients 6 months later (-14.6 vs -11.7 mm Hg, P=0.005), reported researchers led by Lipika Samal, MD, MPH, of Brigham and Women’s Hospital in Boston, in JAMA Internal Medicine.

More patients in the intervention group also received an action aligned with CDS recommendations than those in the usual-care group (49.9% vs 34.6%, P<0.001). This includes increased prescriptions of angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) and orders for a basic metabolic panel or a nephrology electronic consult.

However, the electronic health record (EHR)-based CDS ultimately made no significant difference in the likelihood of patients achieving BP control, defined as staying under 140/90 mm Hg at 180 days (50.4% vs 47.1%).

“Studies have shown that PCPs are not always aware of CKD management guidelines and face barriers to implementing them. Computerized CDS systems aim to close this gap by providing PCPs with person-specific information and timely evidence-based recommendations,” Samal and colleagues wrote.

“The positive results of this study could be related to the behavioral economic elements of the intervention, which may be generalizable to other conditions,” they added. “For example, our results align with those of a 2023 study conducted in a primary care setting in which the incorporation of behavioral economic components, like nudges, yielded statistically significant effects on statin prescribing.”

Hypertension is fairly common in patients with CKD, present in anywhere from 60% to 90% of the patient population, Samal’s group said, noting that it is crucial to manage hypertension as it can be associated with both worse kidney outcomes and increased cardiovascular morbidity and mortality.

Hypertension treatment in CKD remains suboptimal in primary care settings despite the critical role of PCPs in identifying patients with CKD and addressing risk factors before sending them off to specialist care.

Nephrologist John He, MD, PhD, of Mount Sinai in New York City, told MedPage Today that the study’s findings could help strengthen the relationship between PCPs and specialists, potentially smoothing out the transition from one physician to the next and building the confidence of all involved, particularly in regard to prescriptions.

The CDS tool tested had five algorithms inserted into Epic Systems software that triggered alerts and recommendations for specific disease subpopulations encountered in clinical practice. These prompts recommended orders such as automatic opt-in for higher doses of medication and a basic metabolic panel, and an option for a nephrology electronic consult. Patient-specific data were provided to explain why the CDS was triggered in each instance.

He, who was not involved in the study, commented that a computerized tool like this can help PCPs make the right decision, particularly if they are not familiar with all the BP-lowering drugs and guidelines. “That can help them too, in that they feel more confident because they have a computer system to help them make decisions, so they’ll feel more comfortable.”

Samal’s team tested their EHR-based CDS tool in a trial that enrolled attending physicians, physician assistants, and nurse practitioners providing primary care in Brigham and Women’s primary care network. Clinicians were randomized in the study as matched pairs, with one assigned the CDS tool and the other usual care, and their patients with confirmed CKD and uncontrolled hypertension were rolled into the same study arm.

The intervention PCPs had been asked to follow recommendations about BP management or, if they chose not to do so, to enter an accountable justification. An email including a brief statement about CKD guidelines was sent to PCPs in the usual-care group.

In the end, there were 87 PCPs with 1,029 patients randomized to the intervention cohort and 87 PCPs with 997 patients randomized to the usual-care cohort.

Baseline clinical characteristics were generally comparable between study groups with the exception of the intervention arm having more women (65% vs 56%) and an imbalance in diastolic BP.

Overall, 60% of the patients were women and the average age was 75 years old. The cohort was 71% white, 18% Black, and 13% Hispanic. Baseline hypertension treatment was recorded in 85% of cases, and the average systolic BP was 154 mm Hg. Mean BMI was 28.96. The most common comorbidity was hypercholesterolemia (84%), followed by type 2 diabetes (66%). Less than 1% of patients had received a kidney transplant.

Four out of five individuals had a systolic BP measurement at 180 days for the primary endpoint analysis.

Limitations to the study include relying on the first measurement of BP, which is often falsely elevated, and some attrition of PCPs after randomization, Samal and colleagues acknowledged.

He suggested that direct feedback from PCPs could prove helpful for understanding just how a CDS system would work when implemented in a clinical setting.

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