Multi-Center Health Informatics to Examine the Implementation of Guideline-Directed Medical Therapy in Chronic Kidney Disease

Abstract

Background: Chronic kidney disease (CKD) management was largely centered around renin-angiotensin-aldosterone system inhibitors (RAASi) optimization, until recent emergence of novel therapeutics. However, slow adoption of guideline-directed therapy leaves patients vulnerable to disease progression. In 2022, a data-driven informatics approach was introduced to track real-time adherence to best practices. Methods: This multi-center, ambidirectional cohort study analyzed data from a shared electronic health record system in a public healthcare cluster in Singapore, comprising 7 primary care institutions and 3 tertiary care hospitals. Patients aged ≥21 with CKD, managed between 1st March 2022 and 31st March 2024, were included. Prescription trends for RAASi, sodium-glucose co-transporter-2 inhibitors (SGLT2i), non-steroidal mineraloreceptor antagonists, and statins were examined, alongside albuminuria monitoring and comprehensive care uptake. Results: Among 34 217 patients, mean age was 72 ± 12 years; 57% received RAASi, 21% SGLT2i, and 66% statins. Among those meeting therapeutic indications, RAASi uptake remained stable at 74%, with 40% receiving ceiling doses. SGLT2i uptake doubled but remained below 40%, with lower adoption in non-diabetic and non-obese patients. Only 21% of albuminuric CKD G1-3b patients received optimal combination therapy with RAASi, SGLT2i, and statins despite only 4% hyperkalemia prevalence and 2% with systolic BP <110 mmHg. Among albuminuric CKD G3 patients with 5-year end-stage kidney disease risk ≥15%, 28% received optimal therapy. One-third lacked albuminuria monitoring and were less likely to receive comprehensive therapy. Conclusions: Gaps persist in CKD care, particularly among non-diabetic, non-obese patients, and those without albuminuria monitoring. Health informatics-driven interventions can facilitate real-time process evaluation and adherence to best practices amid evolving treatment landscapes.