1
Nimish Mehta, PhD, MBA 1 ; Anne Le, PharmD, RPh 1 1 Medscape, LLC, New York, NY, USA Success of Educational Interventions in the Management of CKD-MBD Success of Educational Interventions in the Management of CKD-MBD purpose Chronic kidney disease (CKD) is associated with numerous adverse outcomes, among them bone disorders, fractures, and cardiovascular disease. Mineral and bone disorders (MBD) in patients with CKD are frequently underrecognized and inadequately treated. 1,2 A study was conducted to determine if on-line educational interventions could improve competence and performance of nephrologists and cardiologists with respect to CKD-MBD management. methods • A cohort of practicing nephrologists and cardiologists in the United States who participated in 1 to 3 educational interventions designed to address gaps in the care of patients with CKD-MBD were assessed. 3-5 • The outcomes survey method to measure competence and performance included knowledge- and case-based multiple-choice questions derived from current clinical recommendations. The domains assessed included identifying and assessing abnormalities in calcium, phosphorous, PTH, and vitamin D levels; individualizing a treatment plan; and identifying cardiovascular risk factors. • The survey was fielded to participants at the completion of each educational intervention. Results were then compared with responses from demographically similar control groups in order to determine the impact of the education. • Confidentiality of survey respondents was maintained and responses were de-identified and aggregated prior to analysis. • Non-practicing clinicians and clinicians not involved in the care of patients with CKD-MBD were excluded from the study. • Chi-square tests were conducted to detect differences between the responses of the participant and nonparticipant groups. For each educational intervention, 200 nephrologists and cardiologists were assessed, divided equally between participants in the education and a matched control group of nonparticipants. Significant improvements were found as a result of participation in the educational interventions with a medium effect size of 0.47 to 0.51 across the 3 activities. Specifically, participants in the education were more likely than nonparticipants to determine: • A greater calcium intake than output in a patient with CKD, resulting in a positive calcium balance (Figure 1) • The role of the vitamin D-independent pathway for calcium absorption (nephrologists 56% vs 32%, P=.02; cardiologists 36% vs 18%, P=.04) • A patient with CKD who needed to reduce phosphorus intake without changing protein intake to lower risk for development of vascular calcification (Figure 2) • Influence of diurnal fluctuation in serum phosphorus levels and dietary protein intake on a patient’s serum phosphorus measurements (Figure 3) • Increased risk of cardiovascular calcification with calcium- containing phosphorus binders (cardiologists 52% vs 33%, P=.05) • Significant dietary protein restriction can lead to an increased mortality risk (cardiologists 54% vs 12%, P<.001) results Conclusions This study demonstrated the success of targeted, online educational interventions designed to address specific identified practice gaps on improving the practice patterns of nephrologists and cardiologists in the assessment and management of patients with CKD-MBD. Statistically significant improvements in several domains of CKD-MBD management may result in improvements in patient care and outcomes. References 1. Joy MS, Karagiannis PC, Peyeri FW. Outcomes of secondary hyperparathyroidism in chronic kidney disease and the direct costs of treatment. J Managed Care Pharm. 2007;13:397-411. 2. Mahajan A, Qiu J, Stark PC, et al. Prevalence of ICD-9-CM codes for chronic kidney disease in individuals with cardiovascular disease risk factors. J Nephrol. 2009;22:523-533. 3. Langman CB, Ix JH. Best Practices in CKD-MBD: Identifying Variability and Modifying Treatment. Medscape Education. December 21, 2012. http://www.medscape.org/viewarticle/775956. Accessed October 27, 2013. 4. Bushinsky DA, Raggi P, Block GA, Spiegel DM. Cardiovascular Implications in CKD: Focus on Calcium Balance. Medscape Education. February 25, 2013. http://www.medscape.org/viewarticle/779165. Accessed October 27, 2013. 5. Chonchol MB, Jamal SA. Incorporating Phosphorus and Calcium Management Strategies Into the Care of Patients With CKD. Medscape Education. February 28, 2013. http://www.medscape.org/viewarticle/779719. Accessed October 27, 2013. Acknowledgements The educational interventions and outcomes measurement were funded through an independent educational grant from Sanofi Renal. Poster layout was provided by Christopher Clarke and Irina Kogan of Medscape Education. For more information, contact Nimish Mehta, PhD, MBA, Senior Director, Educational Strategy, Medscape, LLC, [email protected]. figure 1 Estimation of calcium balance in a patient with CKD taking calcium supplements. Positive* Negative Neutral Nephrology nonparticipants (n=50) Cardiology nonparticipants (n=50) Nephrology participants (n=50) Cardiology participants (n=50) 100% 80% 60% 40% 20% 0% 60% 22% 18% 40% 40% 20% 80% 14% 6% 74% 14% 12% Nephrology P =.03 Cardiology P =.001 A 62-year-old man with a 30-year history of hypertension and hypercholesterolemia was originally referred to you for a creatinine of 1.7 mg/dL. During a recent work up for gastric banding, it was discovered that his hemoglobin A1c was 6.5%. Subsequently, he lost 60 pounds, bringing his BMI to 34. You order a calcium, phosphorus, PTH levels, and 25-hydroxy vitamin D level. He tells you that his wife was recently diagnosed with osteoporosis and has been trying to get him to eat more dairy products but he does not care for them. So he is taking 2 grams of calcium carbonate in the mornings an hour before breakfast with her. figure 2 Advice to aid in limiting development of vascular calcification in a patient with CKD. Do nothing; there is evidence that serum phosphorus levels vary widely over the course of the day Lower the phosphorus content of his diet, but do not lower protein intake* Add a phosphorus binder to his diet Take over-the-counter calcium and vitamin D supplements 2% 61% 35% 2% 7% 30% 57% 7% 0% 88% 11% 2% 11% 73% 14% 2% figure 3 Factors affecting serum phosphorus levels in CKD. What is this patient’s calcium balance? Nephrology nonparticipants (n=54) Cardiology nonparticipants (n=46) Nephrology participants (n=56) Cardiology participants (n=44) 100% 80% 60% 40% 20% 0% Nephrology P =.001 Cardiology P <.001 A 52-year-old African American man with hypertension, dyslipidemia, and stage 2 CKD presents for a routine evaluation. You have followed him for about 5 years. He reports that he recently lost his health insurance, and without prescription coverage, he has been without many of his medications for about a month. You review his medication list with him to separate his medications into 2 groups. The first group includes those medications that have been shown to prolong life or lower risk of poor clinical outcomes. The second group includes those that affect a marker of risk but have not themselves been shown to prolong life. For example, his beta-blocker is in the first group and is deemed essential. His alpha-blocker is in the second group – even though it lowers his blood pressure, it has not been definitively shown to affect lifespan. He will only try to fill the prescriptions in the group that have been proven to really affect his risk of morbidity and mortality. The patient returns periodically for check-ups. He has a new job and has regained health insurance. Over the next year, you note that his creatinine has risen slightly, and he now is in stage 3 CKD. His laboratory tests reveal no evidence of bone and mineral metabolism disorders. At his next appointment, review of the test results reveals: calcium = 9.0 mg/dL and phosphorus = 4.8 mg/dL. At his next follow-up, his serum phosphorus measures 5.3 mg/dL (upper limit of normal for phosphorus in the laboratory that you are using is 5.0 mg/dL). What is the best advice you can give him to limit his development of vascular calcification? Diurnal fluctuation in serum phosphorus levels and dietary intake of protein* Dietary intake of protein and dietary alcohol intake Change in menopausal status and smoking status Dietary alcohol use and smoking status 54% 46% 0% 0% 27% 50% 8% 15% 81% 13% 2% 4% 81% 17% 0% 2% Nephrology nonparticipants (n=52) Cardiology nonparticipants (n=48) Nephrology participants (n=52) Cardiology participants (n=48) 100% 80% 60% 40% 20% 0% Nephrology P =.003 Cardiology P <.001 A 65-year-old woman presents with complaint of progressive exertional dyspnea over the last 2 years. She denies any prior history of significant cardiovascular events. Her past medical history is significant for type 2 diabetes diagnosed at age 55. When she was diagnosed with diabetes she had macro albuminuria and creatinine of 0.8 mg/dL. An ACE inhibitor was initiated at that time, and her creatinine has slowly risen over the years, currently ranging between 1.5 and 2.0 mg/dL. Her laboratories include: Phosphorus, 5.8 mg/dL; calcium, 9.1 mg/dL; eGFR, 36 mL/min; PTH, 24 pg/dL; 25-Hydroxy Vitamin D, 35 ng/mL. Before initiating treatment to lower her phosphorus level, you decide to recheck it. Which of the following factors can affect her serum phosphorus level on recheck?
