Clinical decision support improves physician guideline adherence for laboratory monitoring of chronic kidney disease: a matched cohort study

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Background

The implementation of existing clinical guidelines for chronic kidney disease (CKD) is inadequate. This article evaluates how guideline-based Clinical Decision Support System (CDSS) affects laboratory monitoring of patients with Stage 3-4 Chronic Kidney Disease, an attaining laboratory goals in those patients. [1]

Methods

A cohort study was conducted on 12,353 patients (18 and older) with Stage 3-4 CKD whose physicians used automated guideline CDSS with CKD-related laboratory results and 42,996 patients (control group) whose physicians did not use the CDSS. The physicians used the laboratory company, LabCorp.

The Laboratory tests analyzed estimated glomerular filtration rate, plasma parathyroid hormone, serum calcium, phosphorus, 25-hydroxy vitamin D (25-D), total carbon dioxide, transferrin saturation (TSAT), LDL cholesterol (LDL-C), blood hemoglobin, and urine protein measurements. The percentage of laboratory test retrieved within the recommended interval established in the guideline, was then compared to the percentage of results established guideline target ranges between CDSS and non-CDSS patients.

Results

Patients whose physicians used automated laboratory CDSS, ordered all relevant CKD testing in accordance with the clinical guidelines that those patients whose physicians did not use the CDSS. An increase in the odds of physician adherence to the clinical guideline for CDSS relative to non-CDSS was noted in phosphorous 988%) as well as other tests. Physicians using CDSS, also achieved better laboratory outcomes for LCL-C and 25-D. Refer to the appendix for more result.

Conclusions

Adherence of physicians to clinical guidelines for timely monitoring of CKD can be greatly improved with the implementation of an automated laboratory-based CDSS.

Appendix

  • Lab measurement frequency and range targets used in the analysis. [2]
  • Baseline patient characteristics. [3]
  • Estimated odds ratio for ordering laboratory tests within guideline-recommended intervals: CDSS vs Controls. [4]
  • Effect of CDSS on adherence to guideline testing intervals for eGFR. [5]
  • Effect of CDSS on adherence to guideline testing intervals for phosphorus (a) and PTH (b). [6]
  • Effect of CDSS on adherence to guideline testing intervals for LDL-C (a) and Urine Panels (b). [7]
  • Effect of CDSS on achievement of guideline targets for LDL cholesterol (a) and 25-D (b). [8]
  • Estimated odds ratio for achieving guideline-recommended laboratory test targets: CDSS vs Controls. [9]

My Comments

I liked this article because of the large sample size used and the extensiveness of the study. I also found it interesting that a similar study was done in Canada, which yielded different outcomes than the US study. I don't really have any critiques. I would like to see this study conducted with different clinical guidelines for other diseases. For example, a CDSS to improve physician guideline adherence for laboratory monitoring of heart disease or diabetes mellitus.

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References

  1. Ennis, J., Gillen, D., Rubenstein, A., Worcester, E., Brecher, M. E., Asplin, J., & Coe, F. (2015). Clinical decision support improves physician guideline adherence for laboratory monitoring of chronic kidney disease: a matched cohort study. BMC nephrology, 16(1), 163. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4608162/
  2. Lab measurement frequency and range targets used in the analysis. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4608162/table/Tab1/
  3. Baseline patient characteristics http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4608162/table/Tab2/
  4. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4608162/table/Tab3/
  5. Effect of CDSS on adherence to guideline testing intervals for eGFR. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4608162/figure/Fig1/
  6. Effect of CDSS on adherence to guideline testing intervals for phosphorus (a) and PTH (b). http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4608162/figure/Fig2/
  7. Effect of CDSS on adherence to guideline testing intervals for LDL-C (a) and Urine Panels (b). http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4608162/figure/Fig3/
  8. Effect of CDSS on achievement of guideline targets for LDL cholesterol (a) and 25-D (b). http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4608162/figure/Fig4/
  9. Estimated odds ratio for achieving guideline-recommended laboratory test targets: CDSS vs Controls. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4608162/table/Tab4/