Chronic Kidney Disease Registry Promotes Population Health Management
Electronic health record (EHR) based chronic kidney disease (CKD) registries are central to population health strategies to improve CKD care. In 2015, Partners HealthCare leveraged its Epic system to develop an EHR-based CKD registry to identify opportunities for quality improvement, defined as improvement on both process measures and outcomes measures associated with clinical care. A recent article in BMC Nephrology, co-authored by Mallika Mendu, MD, MBA, Associate Medical Director for Specialty Care at Partners Population Health, Sree Chaguturu, MD, Chief Population Health Officer for Partners HealthCare, and Tom Sequist, MD, Chief Quality and Safety Officer for Partners HealthCare, among others, explored whether leveraging a CKD Registry could identify care gaps across the spectrum of Chronic Kidney Disease care and enable population health strategy implementation.
Chronic kidney disease (CKD) affects over 25 million adults in the United States. CKD, most often caused by diabetes or uncontrolled high blood pressure, can lead to anemia, weak bones, poor nutritional health, and nerve damage. As the disease progresses, kidneys are less able to filter wastes and excess fluids from the blood, which means dangerous levels of fluid, electrolytes, and wastes can build up in the body. Once the kidneys have reached this point, called End Stage Renal Disease or ESRD, patients must receive dialysis for the rest of their life or receive a kidney transplant.
Unfortunately, as patients progress from CKD to ESRD they experience an increased risk of death, ranging from 20 percent risk for Stage 3 CKD to 300 percent risk for stages 4 and 5 CKD, when compared to CKD patients with stage 1 and 2 markers. Not only does CKD carry a severe clinical burden for both patients and providers, there is also a substantial financial burden—generating annual costs nationwide of $23 billion for ESRD management and nearly $50 billion for non-ESRD related CKD management.
“CKD is an under-recognized but growing public health issue,” said Mallika Mendu, MD, MBA, one of the paper’s authors. “Identifying patients with CKD and potential opportunities to improve care at earlier stages of CKD is needed to slow CKD progression and improve clinical outcomes for patients. Nationally, the current model of care is significantly focused on ESRD patients as opposed to the entire continuum of care.”
Given the significant burdens associated with Chronic Kidney Disease, it is imperative to develop population health strategies to address CKD care. Clinical registries, particularly those based on electronic health records (EHR), form the foundation of such population-based improvement activities. These registries facilitate identification of patients, capture clinical quality metrics, and track clinical outcomes across the entire continuum of care for a chronic disease. Registries, used alongside high-risk care management, have been proven to yield significant improvements in clinical outcomes.
As of 2017, the Partners HealthCare CKD registry includes 60,503 patients and has helped identify several opportunities for care improvement including:
- Annual proteinuria testing was performed for only 17% (stage 3) and 31% (stage 4) of patients (guidelines recommend annual testing for all patients);
- Angiotensin-converting enzyme inhibitor/Angiotensin II Receptor Blocker (ACE-I/ARB) used in 41% (stage 3) and 46% (stage 4) of patients;
- Nephrotoxic medications used among 23% of stage 4 patients;
- 89% of stage 4 patients lack HBV immunity.
- For advanced CKD patients there are opportunities to improve vascular access placement in preparation for dialysis, transplant referrals to facilitate transplant before the need for dialysis and outpatient nephrology contact to facilitate close monitoring of patients at risk for progression to dialysis.
Based on the results, our researchers feel that the CKD registry is a valuable tool to help identify modifiable care gaps across the spectrum of CKD care and enable population health strategy implementation.
“What’s exciting about what we have done with the CKD registry here at Partners is now we have a tool to identify all of our CKD patients based on objective criteria, and understand some of the key areas to focus on to improve outcomes for patients,” says Dr. Mendu. “Our focus initially will be on patients with more advanced CKD with goal of slowing their progression to dialysis and facilitating transplantation before dialysis is needed.”