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IIR 19-069 – HSR Study

IIR 19-069
Optimizing Renin Angiotensin System Blocker Use among Veterans with Kidney Disease
Sankar Navaneethan, MD
Michael E. DeBakey VA Medical Center, Houston, TX
Houston, TX
Funding Period: October 2020 - September 2025


Background: Prevalence of moderate to severe chronic kidney disease (CKD) is 70% higher in veterans than the general population. Annual cost for non-dialysis dependent CKD population care increased to $18 billion in FY 2016 for Veterans Administration. Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARBs) are considered standard of care for CKD patients as they improve cardiovascular outcomes and retard progression to end stage kidney disease. Among veterans with diabetes and CKD, only 66% are on ACEI or ARB with significant variation across facilities. Among the ~34% not receiving ACEI or ARB, it is unclear whether they were started on these agents, started but stopped due to an adverse event or never started on ACEI or ARBs for e.g. due to clinical inertia. ACEI/ARB discontinuation is associated with an increased need for dialysis and a higher risk of mortality. In this proposal, we plan to understand the proportion of underuse of ACEI/ARB attributed to side effects versus clinical inertia using structured datasets and unstructured provider text notes, and barriers to initiation and re-initiation (after being discontinued) of ACEI/ARB. Based on these learnings, we propose to pilot test a communication aid in patient aligned care teams (PACTs), which will assist clinicians to initiate or reinitiate ACEI/ARB therapy in CKD patients. Significance: Successful implementation of the proposed study will help us (a) understand the reasons for lack of initiation of ACEI or ARB and their discontinuation (b) successfully develop, refine and pilot test a communication aid to optimize ACEI/ARB use among CKD population. These could reduce kidney disease progression, an improvement in cardiovascular outcomes and potential cost savings for the VA system. Innovation: The project utilizes both structured and unstructured data using natural language processing (NLP) to understand the full context for underutilization of ACEI or ARBS. Furthermore, we utilize innovative qualitative techniques and human factors bests practices to study and address this important gap in care. Aim 1: To examine reasons for lack of initiation and discontinuation of ACEI or ARBs among CKD patients based on structured data and automated information extraction using NLP. Aim 2: To conduct semi-structured interviews with PACT providers and patients at two tertiary care facilities and their community-based outpatient clinics (CBOCs) to further understand the reasons for lack of initiation or discontinuation of ACEI or ARBs among veterans with CKD. Based on these interviews, we will refine a succinct communication aid targeted towards PACT providers which will allow them to effectively initiate and/or reinitiate ACEI/ARB in CKD patients (including those with prior side effects). Aim3: To pilot test a communication aid for clinicians to improve initiation of ACEI or ARB or re-initiation of ACEI or ARB after being discontinued due to an adverse event. Methodology: For Aim 1, we will identify CKD patients using VA structured datasets and will randomly partition them into training and a test set. We will then train our NLP system to achieve a target sensitivity and specificity of >90% compared with manual chart review to assess reasons for lack of initiation/reinitiation of ACEI/ARB. For Aim 2, we will conduct semi-structured patient and provider interviews to understand barriers towards lack of initiation or reinitiation of ACEI or ARBs in CKD patients. We will then refine the content of a communication aid (using a human factors expert) for use during the pilot trial in Aim 3. For Aim 3, we will conduct a pilot trial. All PACT providers at the intervention sites will receive the communication aid to improve initiation of ACEI/ARB or reinitiation of ACEI/ARB after being discontinued due to an adverse event. At the usual care sites, PACT providers will only receive a quarterly report of the proportion of their CKD patients not on an ACEI/ARB. Our primary outcome is the change in the proportion of CKD patients receiving ACEI/ARBs. Next Steps: If our pilot study in Aim 3 is successful, then we will aim towards a system-wide implementation of our communication aid throughout our VISN to improve ACEI or ARB use in veterans with CKD.

External Links for this Project

NIH Reporter

Grant Number: I01HX002917-01A1

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Journal Articles

  1. Wang Y, Chen B, Ciaccio EJ, Jneid H, Virani SS, Lavie CJ, Lebovits J, Green PHR, Krittanawong C. Celiac Disease and the Risk of Cardiovascular Diseases. International journal of molecular sciences. 2023 Jun 9; 24(12). [view]
  2. Virani SS, Ramsey DJ, Westerman D, Kuebeler MK, Chen L, Akeroyd JM, Gobbel GT, Ballantyne CM, Petersen LA, Turchin A, Matheny ME. Cluster Randomized Trial of a Personalized Clinical Decision Support Intervention to Improve Statin Prescribing in Patients With Atherosclerotic Cardiovascular Disease. Circulation. 2023 May 2; 147(18):1411-1413. [view]
  3. Gregg LP, Richardson PA, Herrera MA, Akeroyd JM, Jafry SA, Gobbel GT, Wydermyer S, Arney J, Hung A, Matheny ME, Virani SS, Navaneethan SD. Documented Adverse Drug Reactions and Discontinuation of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers in Chronic Kidney Disease. American Journal of Nephrology. 2023 May 18; 54(3-4):126-135. [view]
  4. Talha KM, Fonarow GC, Virani SS, Butler J. Glucocentric Drugs in Cardiovascular Disease Protection and Heart Failure. Methodist DeBakey cardiovascular journal. 2022 Dec 6; 18(5):40-53. [view]
  5. Khawaja M, Siddiqui R, Virani SS, Amos CI, Bandyopadhyay D, Virk HUH, Alam M, Jneid H, Krittanawong C. Integrative Genetic Approach Facilitates Precision Strategies for Acute Myocardial Infarction. Genes. 2023 Jun 26; 14(7). [view]
  6. Saseen JJ, Virani SS. Lipid lowering therapy in 2022 and beyond - How far we have come. Progress in Cardiovascular Diseases. 2022 Jan 1; 75:1-3. [view]
  7. Kim JA, Kim SE, El Hachem K, Virk HUH, Alam M, Virani SS, Sharma S, House A, Krittanawong C. Medical Management of Coronary Artery Disease in Patients with Chronic Kidney Disease. The American journal of medicine. 2023 Jun 26. [view]
  8. Isath A, Virani SS, Wang Z, Lavie CJ, Naidu SS, Messerli FH, Krittanawong C. Meta-analysis of Per-Day Step Count and All-Cause Mortality. The American journal of cardiology. 2022 Oct 1; 180:166-168. [view]
  9. Deo SV, Al-Kindi S, Virani SS, Fremes S. Novel therapies to achieve the recommended low-density lipoprotein cholesterol concentration (LDL-C) targets for patients after coronary artery bypass grafting. The Journal of Thoracic and Cardiovascular Surgery. 2023 Jun 5. [view]
  10. Gregg LP, Ramsey DJ, Akeroyd JM, Jafry SA, Matheny ME, Virani SS, Navaneethan SD. Predictors, Disparities, and Facility-Level Variation: SGLT2 Inhibitor Prescription Among US Veterans With CKD. American journal of kidney diseases : the official journal of the National Kidney Foundation. 2023 Jul 1; 82(1):53-62.e1. [view]
  11. Ali S, Navaneethan SD, Virani SS, Gregg LP. Revisiting diuretic choice in chronic kidney disease. Current Opinion in Nephrology and Hypertension. 2022 Sep 1; 31(5):406-413. [view]
  12. Belur AD, Shah AJ, Virani SS, Vorla M, Kalra DK. Role of Lipid-Lowering Therapy in Peripheral Artery Disease. Journal of clinical medicine. 2022 Aug 19; 11(16):4872. [view]
  13. Virani SS. Statins and Primary Atherosclerotic Cardiovascular Disease Prevention-What We Know, Where We Need to Go, and Why Are We Not There Already? JAMA Network Open. 2022 Aug 1; 5(8):e2228538. [view]
  14. Virani SS. The Fibrates Story - A Tepid End to a PROMINENT Drug. The New England journal of medicine. 2022 Nov 24; 387(21):1991-1992. [view]
  15. Virani SS, Aspry K, Dixon DL, Ferdinand KC, Heidenreich PA, Jackson EJ, Jacobson TA, McAlister JL, Neff DR, Gulati M, Ballantyne CM. The importance of low-density lipoprotein cholesterol measurement and control as performance measures: A joint clinical perspective from the National Lipid Association and the American Society for Preventive Cardiology. American journal of preventive cardiology. 2023 Mar 1; 13:100472. [view]
  16. Virani SS, Aspry K, Dixon DL, Ferdinand KC, Heidenreich PA, Jackson EJ, Jacobson TA, McAlister JL, Neff DR, Gulati M, Ballantyne CM. The importance of low-density lipoprotein cholesterol measurement and control as performance measures: A joint Clinical Perspective from the National Lipid Association and the American Society for Preventive Cardiology. Journal of clinical lipidology. 2023 Feb 27; 17(2):208-218. [view]

DRA: Kidney Disorders
DRE: Treatment - Efficacy/Effectiveness Clinical Trial, TRL - Applied/Translational
Keywords: Patient-Provider Interaction, Symptom Management
MeSH Terms: None at this time.

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