Chronic kidney disease (CKD) is widely prevalent, associated with morbidity and mortality, but may be lessened with timely implementation of evidence-based strategies including blood pressure (BP) control. Nonetheless, an evidence-practice gap persists. We synthesize the evidence for clinician-facing interventions to improve hypertension management in CKD patients in primary care.
Electronic databases and related publications were queried for relevant studies. We used a conceptual model to address heterogeneity of interventions. We conducted a quantitative synthesis of interventions on blood pressure (BP) outcomes and a narrative synthesis of other CKD relevant clinical outcomes. Planned subgroup analyses were performed by (1) study design (randomized controlled trials (RCTs) or nonrandomized studies (NRS)); (2) intervention type (guideline-concordant decision support, shared care, pharmacist-facing); and (3) use of behavioral/implementation theory.
Of 2704 manuscripts screened, 73 underwent full-text review; 22 met inclusion criteria. BP target achievement was reported in 15 and systolic BP reduction in 6 studies. Among RCTs, all interventions had a significant effect on BP control, (pooled OR 1.21; 95% CI 1.07 to 1.38). Subgroup analysis by intervention type showed significant effects for guideline-concordant decision support (pooled OR 1.19; 95% CI 1.12 to 1.27) but not shared care (pooled OR 1.71; 95% CI 0.96 to 3.03) or pharmacist-facing interventions (pooled OR 1.04; 95% CI 0.82 to 1.34). Subgroup analysis finding was replicated with pooling of RCTs and NRS. The five contributing studies showed large and significant reduction in systolic BP (pooled WMD − 3.86; 95% CI − 7.2 to − 0.55). Use of a behavioral/implementation theory had no impact, while RCTs showed smaller effect sizes than NRS.
Process-oriented implementation strategies used with guideline-concordant decision support was a promising implementation approach. Better reporting guidelines on implementation would enable more useful synthesis of the efficacy of CKD clinical interventions integrated into primary care.
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Allen AS, Forman JP, Orav EJ, Bates DW, Denker BM, Sequist TD. Primary care management of chronic kidney disease. J Gen Intern Med. 2011;26(4):386-92.
Webster AC, Nagler EV, Morton RL, Masson P. Chronic kidney disease. Lancet. 2017;389(10075):1238-52.
Coresh J, Selvin E, Stevens LA, Manzi J, Kusek JW, Eggers P, et al. Prevalence of chronic kidney disease in the United States. JAMA. 2007;298(17):2038-47.
Jha V, Garcia-Garcia G, Iseki K, Li Z, Naicker S, Plattner B, et al. Chronic kidney disease: global dimension and perspectives. Lancet. 2013;382(9888):260-72.
Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet. 2003;362(9391):1225-30.
Levey AS, Schoolwerth AC, Burrows NR, Williams DE, Stith KR, McClellan W. Comprehensive public health strategies for preventing the development, progression, and complications of CKD: report of an expert panel convened by the Centers for Disease Control and Prevention. Am J Kidney Dis. 2009;53(3):522-35.
K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis. 2002;39(2 Suppl 1):S1-266.
Lea JP, McClellan WM, Melcher C, Gladstone E, Hostetter T. CKD risk factors reported by primary care physicians: do guidelines make a difference? Am J Kidney Dis. 2006;47(1):72-7.
Kovacs E, Strobl R, Phillips A, Stephan AJ, Muller M, Gensichen J, et al. Systematic review and meta-analysis of the effectiveness of implementation strategies for non-communicable disease guidelines in primary health care. J Gen Intern Med. 2018;33(7):1142-54.
Galbraith L, Jacobs C, Hemmelgarn BR, Donald M, Manns BJ, Jun M. Chronic disease management interventions for people with chronic kidney disease in primary care: a systematic review and meta-analysis. Nephrol Dial Transplant. 2018;33(1):112-21.
LLC SC; Pages www.stata.com.
Silver SA, Bell CM, Chertow GM, Shah PS, Shojania K, Wald R, et al. Effectiveness of quality improvement strategies for the management of CKD: a meta-analysis. Clin J Am Soc Nephrol. 2017;12(10):1601-14.
Elliott MJ, Gil S, Hemmelgarn BR, Manns BJ, Tonelli M, Jun M, et al. A scoping review of adult chronic kidney disease clinical pathways for primary care. Nephrol Dial Transplant. 2017;32(5):838-46.
Xu H, Mou L, Cai Z. A nurse-coordinated model of care versus usual care for chronic kidney disease: meta-analysis. J Clin Nurs. 2017;26(11-12):1639-49.
Bello AK, Qarni B, Samimi A, Okel J, Chatterley T, Okpechi IG, et al. Effectiveness of multifaceted care approach on adverse clinical outcomes in nondiabetic CKD: a systematic review and meta-analysis. Kidney Int Rep. 2017;2(4):617-25.
Tesfaye WH, Castelino RL, Wimmer BC, Zaidi STR. Inappropriate prescribing in chronic kidney disease: a systematic review of prevalence, associated clinical outcomes and impact of interventions. Int J Clin Pract. 2017;71(7).
Chen CC, Chen Y, Liu X, Wen Y, Ma DY, Huang YY, et al. The efficacy of a nurse-led disease management program in improving the quality of life for patients with chronic kidney disease: a meta-analysis. PLoS One. 2016;11(5):e0155890.
Wells G, B. Shea, D. O'Connell, J. Peterson, V. Welch, M. Losos, P. Tugwell 2012; Pages on July 15 2018.
Joosten H, Drion I, Boogerd KJ, van der Pijl EV, Slingerland RJ, Slaets JP, et al. Optimising drug prescribing and dispensing in subjects at risk for drug errors due to renal impairment: improving drug safety in primary healthcare by low eGFR alerts. BMJ Open. 2013;3(1).
Shamseer L, Moher D, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015: elaboration and explanation. BMJ. 2015;350:g7647.
Kamath CC, Claudia C. Dobler, Michelle A. Lampman, Patricia J. Erwin, John Matulis, Muhamad Elrashidi, Rozalina G. McCoy, Mouaz Alsawas, Atieh Pajouhi, Amrit Vasdev, Nilay D. Shah, M. Hassan Murad, Bjorg Thorsteinsdottir. Implementation strategies for interventions to improve the management of chronic kidney disease (CKD) by primary care clinicians: protocol for a systematic review. (accepted for publication at BMJ Open). 2019.
Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA. 2002;288(14):1775-9.
Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA. 2002;288(15):1909-14.
Proctor EK, Landsverk J, Aarons G, Chambers D, Glisson C, Mittman B. Implementation research in mental health services: an emerging science with conceptual, methodological, and training challenges. Adm Policy Ment Health. 2009;36(1):24-34.
Powell BJ, Waltz TJ, Chinman MJ, Damschroder LJ, Smith JL, Matthieu MM, et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci. 2015;10:21.
Waltz TJ, Powell BJ, Matthieu MM, Damschroder LJ, Chinman MJ, Smith JL, et al. Use of concept mapping to characterize relationships among implementation strategies and assess their feasibility and importance: results from the Expert Recommendations for Implementing Change (ERIC) study. Implement Sci. 2015;10:109.
Tsang JY, Blakeman T, Hegarty J, Humphreys J, Harvey G. Understanding the implementation of interventions to improve the management of chronic kidney disease in primary care: a rapid realist review. Implement Sci. 2016;11:47.
Collaborations TC. Cochrane Handbook for Systematic Reviews of Interventions. 2011(5.1.0).
KDIGO. “KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease.” Kidney International. 2013.
Higgins JP, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman AD, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928.
Murad MH, Almasri J, Alsawas M, Farah W. Grading the quality of evidence in complex interventions: a guide for evidence-based practitioners. Evid Based Med. 2017;22(1):20-2.
DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3):177-88.
Tan J, McCready F, Noovao F, Tepueluelu O, Collins J, Cundy T. Intensification of blood pressure treatment in Pasifika people with type 2 diabetes and renal disease: a cohort study in primary care. N Z Med J. 2014;127(1404):17-26.
Bhardwaja B, Carroll NM, Raebel MA, Chester EA, Korner EJ, Rocho BE, et al. Improving prescribing safety in patients with renal insufficiency in the ambulatory setting: the Drug Renal Alert Pharmacy (DRAP) program. Pharmacotherapy. 2011;31(4):346-56.
Pourrat X, Sipert AS, Gatault P, Sautenet B, Hay N, Guinard F, et al. Community pharmacist intervention in patients with renal impairment. Int J Clin Pharm. 2015;37(6):1172-9.
Humphreys J, Harvey G, Coleiro M, Butler B, Barclay A, Gwozdziewicz M, et al. A collaborative project to improve identification and management of patients with chronic kidney disease in a primary care setting in Greater Manchester. BMJ Quality and Safety. 2012;21.
Harvey G, Oliver K, Humphreys J, Rothwell K, Hegarty J. Improving the identification and management of chronic kidney disease in primary care: lessons from a staged improvement collaborative. International Journal for Quality in Health Care. 2015;27(1):10-6.
Humphreys J, Harvey G, Hegarty J. Improving CKD diagnosis and blood pressure control in primary care: a tailored multifaceted quality improvement programme. Nephron Extra. 2017;7(1):18-32.
Abdel-Kader K, Fischer GS, Li J, Moore CG, Hess R, Unruh ML. Automated clinical reminders for primary care providers in the care of CKD: a small cluster-randomized controlled trial. Am J Kidney Dis. 2011;58(6):894-902.
Akbari A, Swedko PJ, Clark HD, Hogg W, Lemelin J, Magner P, et al. Detection of chronic kidney disease with laboratory reporting of estimated glomerular filtration rate and an educational program. Arch Intern Med. 2004;164.
Drawz PE, Miller RT, Singh S, Watts B, Kern E. Impact of a chronic kidney disease registry and provider education on guideline adherence—a cluster randomized controlled trial. BMC Med Inform Decis Mak. 2012;12.
Erler A, Beyer M, Petersen JJ, Saal K, Rath T, Rochon J, et al. How to improve drug dosing for patients with renal impairment in primary care—a cluster-randomized controlled trial. BMC Fam Pract. 2012;13.
Fox CH, Swanson A, Kahn LS, Glaser K, Murray BM. Improving chronic kidney disease care in primary care practices: an Upstate New York Practice-Based Research Network (UNYNET) study. J Am Board Fam Med. 2008;21.
Karunaratne K, Stevens P, Irving J, Hobbs H, Kilbride H, Kingston R, et al. The impact of pay for performance on the control of blood pressure in people with chronic kidney disease stage 3–5. Nephrol Dial Transplant. 2013;28.
Litvin CB, Hyer JM, Ornstein SM. Use of clinical decision support to improve primary care identification and management of chronic kidney disease (CKD). Journal of the American Board of Family Medicine: JABFM. 2016;29(5):604-12.
Lusignan S, Gallagher H, Jones S, Chan T, Vlymen J, Tahir A, et al. Audit-based education lowers systolic blood pressure in chronic kidney disease: the quality improvement in CKD (QICKD) trial results. Kidney Int. 2013;84.
Manns B, Tonelli M, Culleton B, Faris P, McLaughlin K, Chin R, et al. A cluster randomized trial of an enhanced eGFR prompt in chronic kidney disease. Clin J Am Soc Nephrol. 2012;7(4):565-72.
Stoves J, Connolly J, Cheung CK, Grange A, Rhodes P, O’Donoghue D, et al. Electronic consultation as an alternative to hospital referral for patients with chronic kidney disease: a novel application for networked electronic health records to improve the accessibility and efficiency of healthcare. Qual Saf Health Care. 2010;19(5):e54.
Xu G, Major R, Shepherd D, Brunskill N. Making an IMPAKT; improving care of chronic kidney disease patients in the community through collaborative working and utilizing Information Technology. BMJ Qual Improv Rep. 2017;6(1).
Al Hamarneh YN, Tsuyuki RT, Jones CA, Manns B, Tonelli M, Scott-Douglass N, et al. Effectiveness of pharmacist interventions on cardiovascular risk in patients with CKD: a subgroup analysis of the randomized controlled RxEACH Trial. Am J Kidney Dis. 2017.
Carter BL, Coffey CS, Ardery G, Uribe L, Ecklund D, James P, et al. Cluster-randomized trial of a physician/pharmacist collaborative model to improve blood pressure control. Circulation. Cardiovascular Quality & Outcomes. 2015;8(3):235-43.
Chang AR, Evans M, Yule C, Bohn L, Young A, Lewis M, et al. Using pharmacists to improve risk stratification and management of stage 3A chronic kidney disease: a feasibility study. BMC Nephrology. 2016;17(1):168.
Cooney D, Moon H, Liu Y, Miller RT, Perzynski A, Watts B, et al. A pharmacist based intervention to improve the care of patients with CKD: a pragmatic, randomized, controlled trial. BMC Nephrology. 2015;16:56.
Via-Sosa MA, Lopes N, March M. Effectiveness of a drug dosing service provided by community pharmacists in polymedicated elderly patients with renal impairment—a comparative study. BMC Fam Pract. 2013;14:96.
Barrett BJ, Garg AX, Goeree R, Levin A, Molzahn A, Rigatto C, et al. A nurse-coordinated model of care versus usual care for stage 3/4 chronic kidney disease in the community: a randomized controlled trial. Clin J Am Soc Nephrol. 2011;6.
Richards N, Harris K, Whitfield M, O’Donoghue D, Lewis R, Mansell M, et al. Primary care-based disease management of chronic kidney disease (CKD), based on estimated glomerular filtration rate (eGFR) reporting, improves patient outcomes. Nephrol Dial Transplant. 2008;23.
Scherpbier-de Haan ND, Vervoort GM, van Weel C, Braspenning JC, Mulder J, Wetzels JF, et al. Effect of shared care on blood pressure in patients with chronic kidney disease: a cluster randomised controlled trial. Br J Gen Pract. 2013;63(617):e798-806.
Thomas N, Gallagher H, Jain N. A quality improvement project to improve the effectiveness and patient-centredness of management of people with mild-to-moderate kidney disease in primary care. BMJ Qual Improv Rep. 2014;3(1).
Yamagata K, Makino H, Iseki K, Ito S, Kimura K, Kusano E, et al. Effect of behavior modification on outcome in early- to moderate-stage chronic kidney disease: a cluster-randomized trial. PLoS One. 2016;11(3):e0151422.
Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health. 2011;38(2):65-76.
Ioannidis JP, Trikalinos TA. The appropriateness of asymmetry tests for publication bias in meta-analyses: a large survey. Cmaj. 2007;176(8):1091-6.
Chambers DA, Norton WE. The adaptome: advancing the science of intervention adaptation. Am J Prev Med. 2016;51(4 Suppl 2):S124-31.
Powell BJ, Fernandez ME, Williams NJ, Aarons GA, Beidas RS, Lewis CC, et al. Enhancing the impact of implementation strategies in healthcare: a research agenda. Front Public Health. 2019;7:3.
Movsisyan A, Melendez-Torres GJ, Montgomery P. Outcomes in systematic reviews of complex interventions never reached “high” GRADE ratings when compared with those of simple interventions. J Clin Epidemiol. 2016;78:22-33.
Tricco AC, Ivers NM, Grimshaw JM, Moher D, Turner L, Galipeau J, et al. Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis. Lancet. 2012;379(9833):2252-61.
Liu H, Mohammed A, Shanthosh J, News M, Laba TL, Hackett ML, et al. Process evaluations of primary care interventions addressing chronic disease: a systematic review. BMJ Open. 2019;9(8):e025127.
We acknowledge Aaron Leppin MD for the implementation science expertise and advice with the study.
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This research was presented in two poster abstracts at the 11th Annual Conference on the Science of Dissemination & Implementation in Health, Academy Health; December 3–5, 2018, Washington DC.
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Kamath, C.C., Dobler, C.C., McCoy, R.G. et al. Improving Blood Pressure Management in Primary Care Patients with Chronic Kidney Disease: a Systematic Review of Interventions and Implementation Strategies. J GEN INTERN MED 35, 849–869 (2020). https://doi.org/10.1007/s11606-020-06103-7
- chronic kidney disease
- blood pressure control
- primary care practitioner interventions
- systematic review
- guideline implementation
- implementation strategies