Use of Guideline-Recommended Medication Therapy in a High-Risk CKD Population in the Kidney CHAMP Trial

Background: Use of guideline-recommended medication therapy to improve kidney and cardiovascular outcomes in patients with chronic kidney disease (CKD) is suboptimal. Kidney CHAMP is a pragmatic randomized controlled trial evaluating the effectiveness of a population health management (PHM) approach to improve CKD care. The intervention leveraged electronic health records to identify patients with CKD at high risk of progression and communicate recommendations from a nephrologist-led e-consult and pharmacist-led medication review to primary care providers (PCP) randomized to the intervention group. We compared the use of guideline-recommended medication therapy in patients in the intervention group vs patients receiving usual care per their PCP. Methods: Eligible patients were 18-85 years with high-risk CKD and not followed by a nephrologist. Guideline-recommended medication therapy included use of ACE inhibitor (ACEi) or angiotensin II receptor blocker (ARB) if baseline urine albumin-to-creatinine ratio (UACR) ≥ 300 mg/g, moderate or high intensity statin if baseline age ≤ 75 years, and SGLT2 inhibitor (SGLT2i) and/or GLP1 receptor agonist (GLP1RA). Changes in medication use between groups were tested using logistic regression via generalized estimating equations. Results: Among 1596 patients enrolled, 58% were females, the mean age was 74 years, mean eGFR 37 mL/min/1.73m2, and mean UACR 410 mg/g at baseline. Comorbidities included hypertension (95%), diabetes (64%), and cardiovascular disease (78%). Over a median 18 month study period, ACEi/ARB use changed from 49% to 43% (p=0.10) vs 51% to 40% (p=0.005), statin use changed from 52% to 55% (p=0.55) vs 54% to 50% (p=0.25), and SGLT2i and/or GLP1RA use changed from 9% to 20% (p<0.001) vs 5% to 13% (p<0.001) in the intervention vs usual care groups, respectively. There was no between group difference in the change in ACEi/ARB (p=0.46), statin (p=0.12), or SGLT2i and/or GLP1RA (p=0.80) use. Conclusions: A PHM approach did not improve use of guideline-recommended medication therapy in patients with high-risk CKD compared to usual care. This research supports a need to address barriers in the primary care setting, including therapeutic inertia and access to clear practice guidelines, and efforts to improve the delivery of CKD care.