A learning health system approach to improving chronic kidney disease management in primary care

BACKGROUND: One in seven U.S. adults has chronic kidney disease (CKD). Early diagnosis and management in primary care can prevent disease progression and cardiovascular complications. OBJECTIVE: The aim was to increase primary care capacity to diagnose and treat patients with early CKD. This primary care-focused CKD improvement program is described in the context of its alignment with Learning Health System principles. DESIGN: Quality improvement with iterative improvement cycles of small-scale, single-site pilot tests focused on CKD recognition and diagnosis, lab testing, medication management, and nephrology referrals. PATIENTS: Patients with CKD or risk factors were included from a large primary care network within a Midwestern U.S. health system. INTERVENTIONS: Multiple strategies were developed and incorporated into four pilot test cycles, with each cycle carried out at a separate practice site. Disease registries and primary care dashboards enhanced actionable patient data. Clinical practice guidelines, clinician education, and clinical decision support tools were targeted to providers and other team roles. Workflows were developed with clinical pharmacists and patient navigators. Nephrology referral guidance was detailed. Leadership support was enlisted at multiple organizational levels. MAIN MEASURES: Outcomes included the number of patients who received a CKD diagnosis, were referred to nephrology, completed an ordered uACR test, and were taking guideline-recommended medications. KEY RESULTS: In four pilot sites covering 1,627 eligible patients, 167 were newly diagnosed with CKD, 488 were ordered urine tests, 80 were referred to nephrology, and a majority had at least one medication changed or added. CONCLUSIONS: Team-based primary care workflows to address widespread CKD care gaps can improve care for a large adult population. Health system leadership support of staffing and EHR resources was necessary for achieving these goals.