Kidney Coordinated Health Management Partnership

To test the effectiveness of a multifaceted Electronic Health Record (EHR)-based Population
Health Management (PHM) intervention to improve the delivery of evidence-based Chronic Kidney
Disease (CKD) care in patients with high-risk CKD. Investigators will perform a 42-month
pragmatic, cluster randomized (at the practice level) controlled trial in 1,650 patients with
high-risk CKD (as defined by validated risk prediction models or by current estimated
Glomerular Filtration Rate (eGFR) value or recent decline in eGFR values) managed by their
Primary Care Physicians (PCPs) to determine whether EHR-based PHM improves key processes of
care and clinical outcomes.

The investigators hypothesize that EHR-based PHM will improve hypertension control, use of
renin angiotensin aldosterone system inhibitors (RAASi), and avoidance of renally
contraindicated medications (Aim 1a-1c) and delay CKD progression (Aim 2).

Investigators will also characterize the acceptability and experience of Primary Care
Physicians (PCPs) in the intervention arm of the CKD PHM study (Aim 3).

Inclusion criteria for PCPs: presence of an ambulatory continuity clinic in the University
of Pittsburgh Medical Center (UPMC) community medicine practice.

Inclusion criteria for patients:

1. age greater than or equal to 18, and less than or equal to 85

2. most recent eGFR less than 60 ml/min/yr

3. established care with UPMC PCP

4. high risk CKD based on validated external and internal risk prediction models or
severe reduction in eGFR, or substantial loss in eGFR in prior 18 months.

Exclusion Criteria for PCPs: none

Exclusion Criteria for patients:

1. history of kidney transplant

2. receiving maintenance dialysis

3. recent (within 12 months) outpatient nephrology visit

4. baseline eGFR less than 15ml/min

5. expected survival less than 6 months or hospice enrollee (e.g., stage IV heart
failure, metastatic cancer, oxygen dependent Chronic Obstructive Pulmonary Disease)

6. active substance dependence or severe/uncontrolled psychiatric condition