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New Study Seeks to Optimize Chronic Kidney Disease Care

February 6, 2020

Manisha Jhamb, MD, MPH

Manisha Jhamb, MD, MPH, is working on a new National Institutes of Health-funded R01 award (R01DK116957) to improve the care of patients with chronic kidney disease (CKD). Dr. Jhamb is an assistant professor of medicine in the Renal-Electrolyte Division whose clinical research focuses on understanding and improving patient-centered outcomes in patients with chronic kidney disease and end-stage renal disease (ESRD).

Dr. Jhamb is particularly interested in testing the effectiveness of clinical interventions to improve patient symptoms and quality-of-life in CKD and ESRD. Her ongoing studies are evaluating technology-based collaborative care interventions on symptoms in dialysis patients. Another focus of her research is using health information technology to improve delivery of CKD care, reduce health disparities in CKD, and develop predictive models to identify high-risk CKD patients.

CKD is associated with an unacceptably high human and financial cost. Gaps in CKD care contribute to catastrophic outcomes such as dialysis dependence. Novel system-based interventions are needed to improve CKD care. Real-time risk stratification and population health management using electronic health records can improve CKD care and outcomes in the patients who need it most. This forms the basis of Dr. Jhamb’s R01 study.

Study Abstract: Kidney-Coordinated HeAlth Management Partnership (Kidney-CHAMP) 

Millions of adults have CKD, leading to substantial morbidity, mortality, and health care costs. These effects are concentrated in patients with high-risk disease. Several provider- and system-level barriers lead to well-described gaps in care for these patients that contribute to poor outcomes. Population health management (PHM) improves patient health by aggregating and analyzing data across a population to drive consistent, evidence-based care. CKD PHM using electronic health records (EHRs) can be a sustainable strategy to overcome physician- and system-level barriers. EHR-based PHM could improve the identification of patients with high-risk CKD; increase the use of evidence-based, widely available, and cost-effective interventions; and enhance medication safety. 

The Kidney-Coordinated HeAlth Management Partnership (Kidney-CHAMP) study (R01DK116957) is testing the effectiveness of a multifaceted EHR-based PHM intervention to improve the delivery of evidence-based CKD care in high-risk patients in the primary care setting. Specifically, it targets: 1) timely identification of high-risk CKD; 2) imple-mentation of remote nephrology guidance (e-consult) to improve evidence-based CKD care; 3) opportunities for pharmacist-led medication safety reviews; and 4) access to standardized CKD patient education. A novel aspect of this study is the delivery of evidence-based nephrology guidance to primary care providers using Targeted Automated electronic Consults (TACo) which are targeted to the high risk patients and use an opt-out approach. This 42-month pragmatic, cluster-randomized, controlled trial in ~1,700 high-risk CKD patients from 330 primary care physicians (PCPs) will evaluate the intervention’s effects on kidney disease progression, key processes of care such as hypertension control, avoidance of nephrotoxic medications, and health care utilization costs. 

Dr. Jhamb has an ancillary study to Kidney-CHAMP (OPTIMIZE; R18DK118460) that will qualitatively identify barriers and facilitators of the intervention’s effectiveness and response heterogeneity in diverse settings and with diverse patient and provider groups. Participants in the study will be selected using purposive sampling from the PCPs and patients who are randomized to the intervention arm in the Kidney-CHAMP study. Semi-structured interviews will be conducted to elicit key physician and patient level predictors that underlie the effectiveness of the intervention in diverse settings. This will allow for refinements of CKD phenotypes and transportability of the intervention in heterogeneous populations. These deliverables would strengthen future trials and specifically address disparity in CKD care by interviewing patients from vulnerable groups including minorities, low socioeconomic status, and those with multimorbidity. Dr. Jhamb’s study is highly complementary and valuable to the evaluation of the Kidney-CHAMP intervention. The proposed qualitative work will further refine future efforts to improve the intervention’s implementation, dissemination, and use in real practice and diverse health care settings.