Primary care strategy did not reduce hospitalizations at one year in kidney-dysfunction triad: ICD-Pieces study

"The hospitalization rate of patients in the intervention group at one year was about the same as that with usual care (20.7% vs 21.1%)," the researchers reported in the ICD-Pieces study published in the New England Journal of Medicine.

Patients with chronic kidney disease (CKD), type 2 diabetes (T2D), and hypertension (the kidney-dysfunction triad) are at high risk for multiple complications, end-stage kidney disease, and premature death. Despite the availability of effective therapies for these patients, there is a lack of results of large-scale trials examining the implementation of guideline-directed therapy to reduce death and complications risk in this population.

Miguel Vazquez, the University of Texas Southwestern Medical Center in Dallas, and colleagues conducted an open-label, cluster-randomized trial including 11,182 patients with the kidney-dysfunction triad being treated at 141 primary care clinics. They were assigned to receive an intervention that used a personalized algorithm (based on the patient’s EHR) to identify patients and practice facilitators to assist providers in delivering guideline-based interventions or to receive usual care.

The study's primary outcome was hospitalization for any cause at 1 year. Secondary outcomes were readmissions, emergency department visits, dialysis, cardiovascular events, and death. Cardiovascular events included heart failure, acute coronary syndrome, and stroke, while cardiovascular procedures included cardiac catheterization and revascularization.

The researchers assigned 71 practices (enrolling 5690 patients) to the intervention group and 70 practices (enrolling 5492 patients) to the usual-care group.

The researchers reported the following findings:

• The hospitalization rate at 1 year was 20.7% in the intervention group and 21.1% in the usual-care group (between-group difference, 0.4 percentage points).
• The risks of emergency department visits, cardiovascular events, readmissions, dialysis, or death from any cause were similar in the two groups.
• The risk of adverse events was also similar in the trial groups, except for acute kidney injury, which was observed in more patients in the intervention group (12.7% vs. 11.3%).

While the intervention missed the mark for reducing hospitalizations, Vazquez highlighted the importance of improving care for patients with the kidney-dysfunction triad.

"In this pragmatic trial involving patients with the kidney-dysfunction triad, using an EHR-based algorithm and practice facilitators embedded in primary care clinics did not translate into reduced hospitalization at 1 year," the researchers concluded.

Reference:

Vazquez MA, et al "Pragmatic trial of hospitalization rate in chronic kidney disease" N Engl J Med 2024; DOI: 10.1056/NEJMoa2311708.