Table of Contents
- Broadly define your planning Team.
- Review population health data to identify care improvement opportunities.
- Build consensus on evidence-based, guideline-driven interventions/quality metrics.
- Prioritize social determinants of health and CKD care disparities within the program.
- Characterize the impact of social determinants of health within geographies considered for your program.
- Clearly communicate collaboration parameters between primary care and nephrology as determined by your Team.
- Identify an implementation framework to assess implementation strategies/associated interventions and their outcomes.
- References
A CKD quality improvement strategy that yields actionable results with desired outcomes requires input and perspective from various healthcare professionals and sources. Following are suggested Team participants and resources to help achieve those objectives.
Broadly define your planning Team.
Consider including representatives from primary care, nephrology, informatics, population health, quality, pharmacy, health equity, nursing, pathology, diabetes care and education specialists, community outreach, dietitians, and others on this team.
Primary Care
Resources:
- J Gen Intern Med, 2011, Chronic Kidney Disease in Primary Care: An Opportunity for Generalists, offers insights into CKD management by those who represent the first line of CKD care—primary care clinicians.(39)
Pharmacy
Resources:
- Am J Health Syst Pharm, 2022, Optimizing use of SGLT2 inhibitors and other evidence-based therapies to improve outcomes in patients with type 2 diabetes and chronic kidney disease: An opportunity for pharmacists, addresses the pivotal role pharmacists can play to improve medication management in type 2 diabetes and CKD.(40)
- Centers for Disease Control and Prevention, Preventing Chronic Disease, 2020, Public Health and Pharmacy: Collaborative Approaches to Improve Population Health, highlights pharmacy contributions to public health and how pharmacy can improve population health.(41)
- Community Pharmacy Enhanced Services Network, Community-Based Pharmacy Solutions for All, a website that provides resources for payers, pharmacies and communities who are collaborating to enhance local health services.
Pathology
Tools:
- NKF, Closing the Testing Gap by Implementing the Kidney Profile, a virtual meeting of laboratory, IT, data informatics, and quality improvement leaders that highlights successful strategies for implementation, discusses and trouble shoots challenges, and identifies strategies to ensure the Kidney Profile is utilized by clinicians once it is implemented
Resources:
- NKF, Laboratory Engagement Initiative, developed by clinical laboratorians and physicians, this overviews guideline-concordant testing for CKD diagnosis and management as well as resources for patients and healthcare professionals.
Informatics
Tools:
- PheKB, Chronic Kidney Disease, the Phenotype KnowledgeBase resource for those interested in using data algorithms to enhance genomic and clinical research including that for CKD.
Resources:
- Clin J Am Soc Nephrol, 2019, Development and validation of a pragmatic electronic phenotype for CKD, a tool that utilizes the EHR to accurately identify patients who likely have CKD(42)
- NPJ Digit Med, 2021, Medical records-based chronic kidney disease phenotype for clinical care and “big data” observational and genetic studies, details a scalable, portable electronic CKD phenotype to facilitate earlier disease detection.(43)
Community Outreach/Community Health Workers
Tools:
- NKF, Community Health Workers, a resource that advances Community Health Workers and their role in connecting patients to health care resources via identification, prevention, and risk management associated with CKD.
Clinical Pharmacists are Widely Under-recognized in their Clinical Expertise as a Resource for Primary Care
"The pharmacotherapy clinic leader said we’re (clinical pharmacists) the best kept secret in the institution. We’re here to address many of the barriers facing primary care physicians and to initiate guideline directed therapies in CKD, including working through prior authorizations that take time and burdens on the primary care clinic."
Joshua J. Neumiller, PharmD, CDCES, FASCP, FADCES
Washington State University
Change Package Faculty
Review population health data to identify care improvement opportunities.
Screening and Diagnosis:
- Electronic Health Record (EHR) and/or claims data to determine rates of guideline-concordant CKD testing (eGFR and uACR) among patients with hypertension and/or diabetes
- Available EHR laboratory data to assess rates of CKD diagnosis among patients with hypertension and/or diabetes and existing laboratory evidence of CKD
- Available EHR laboratory data to determine rates of CKD testing (eGFR and uACR) among patients with a CKD ICD-10 code in their medical record (e.g., BMP with eGFR results <60 mL/min/1.73m2)
- Annual CKD testing (eGFR and uACR) and risk stratification in at-risk populations—those with diabetes and/or hypertension and/or other risk factors
A1C and/or Blood Pressure Goal Attainment:
- Percentage of patients with CKD and diabetes with A1C within recommended range
- Percentage of patients with CKD whose blood pressure is within recommended range
Preventing CKD Progression and/or Reduce Cardiovascular Risk:
- Percentage of patients with CKD and Type 2 Diabetes prescribed GLP-1 RAs
- Percentage of patients with diabetes and/or hypertension on problem list/encounter with a uACR ≥ 30 who were prescribed an ACE inhibitor or ARB medication
- Percentage of patients with Type 2 Diabetes and CKD on problem or encounter list with an eGFR ≥ 20 who were prescribed an SGLT2i medication
- Percentage of patients with Type 2 Diabetes and CKD on problem or encounter list with an eGFR ≥ 25 and uACR ≥ 30 who were prescribed a non-steroidal MRA medication
- Percentage of individuals aged 18 years and older with a diagnosis of CKD who were prescribed select SGLT2i therapy within a 12-month period
- Percentage of individuals with heart failure, Type 2 diabetes/atherosclerotic cardiovascular disease and CKD prescribed select SGLT2i therapy within a 12-month period
Tools:
- Am J Med, 2016, Practical Approach to Detection and Management of Chronic Kidney Disease for the Primary Care Clinician, guidance for assessing and managing CKD in primary care derived from the Kidney Disease Outcomes Quality Initiative (KDOQI)(19)
- NKF, Chronic kidney disease data analysis strategy, a concise overview of unrecognized CKD and data mining parameters
Build consensus on evidence-based, guideline-driven interventions/quality metrics.
Consider evaluation and selection of interventions/quality metrics on the basis of what is appropriate for clinic locations, patient panels, resources, and workflows.
Identify evidence-based recommendations and guidelines that support CKD recognition and implementation of interdisciplinary patient care for CKD
Tools:
- American Diabetes Association, (ADA) 11. Chronic Kidney Disease and Risk Management: Standards of Care in Diabetes—2023(46)
- Kidney Disease: Improving Global Outcomes (KDIGO), 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease(6)
- Kidney Disease Quality Outcomes Initiative (KDOQI), US Commentary on the 2012 KDIGO Clinical Practice Guideline for the Evaluation and Management of CKD(47)
- J Diabetes Complications, 2022, Diabetes, Cardiorenal, and Metabolic (DCRM) Multispecialty Practice Recommendations for the Management of Diabetes, Cardiorenal, and Metabolic diseases(48)
- Ann Intern Med, 2023, Diabetes Management in Chronic Kidney Disease: Synopsis of the KDIGO 2022 Clinical Practice Guideline Update(49)
- American Society for Pathology (ASCP), 2020, Choosing Wisely an Initiative of the American Board of Internal Medicine (ABIM)(6)
- U.S. Department of Veterans Affairs/Department of Defense (VA/DoD), Clinical Practice Guidelines Management of Chronic Kidney Disease (CKD) (2019)
Annual CKD testing (eGFR and uACR) and risk stratification in at-risk populations—those with diabetes and/or hypertension and/or other risk factors
Tools:
- American Diabetes Association, (ADA) 11. Chronic Kidney Disease and Risk Management: Standards of Care in Diabetes—2023(46)
- Kidney Disease: Improving Global Outcomes (KDIGO), 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease(6)
- American Society for Pathology (ASCP), 2020, Choosing Wisely an Initiative of the American Board of Internal Medicine (ABIM)(6)
Attainment of blood pressure target
Tools:
- American Academy of Family Physicians (AAFP), 2022, Blood Pressure Targets in Adults with Hypertension: A Clinical Practice Guideline From the AAFP
- Kidney Disease: Improving Global Outcomes (KDIGO), 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease(50)
- Kidney Disease Quality Outcomes Initiative (KDOQI), US Commentary on the 2012 KDIGO Clinical Practice Guideline for Management of Blood Pressure in CKD(51)
Attainment of A1c target
Tools:
- American Diabetes Association, (ADA) Standards of Care in Diabetes—2023 Abridged for Primary Care Providers
- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)Guiding Principles for the Care of Patients with or at Risk for Diabetes
Use of ACE Inhibitor or Angiotensin Receptor Blocker in patients with diabetic kidney disease, CKD and HTN, and/or CKD and uACR > 30 where tolerated and appropriate
Tools:
- Kidney Disease Quality Outcomes Initiative (KDOQI), US Commentary on the 2012 KDIGO Clinical Practice Guideline for the Evaluation and Management of CKD(25)
- U.S. Department of Health and Human Services (HHS), Healthy People 2030: Increase the proportion of patients on Medicare with chronic kidney disease who get recommended tests
Use of an SGLT-2i in patients with CKD and eGFR >20 where tolerated and appropriate
Tools:
- American Diabetes Association, (ADA) 11. Chronic Kidney Disease and Risk Management: Standards of Care in Diabetes—2023(46)
- American Diabetes Association/Kidney Disease: Improving Global Outcomes (ADA/KDIGO), 2022, Diabetes management in chronic kidney disease: a consensus report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO)(52)
- Am J Kidney Disease, 2020, SGLT2 Inhibition for CKD and Cardiovascular Disease in Type 2 Diabetes: Report of a Scientific Workshop Sponsored by the National Kidney Foundation.(54)
Use of Statins
Tools:
- ACC/AHA, 2019, Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines(55)
- Kidney Disease: Improving Global Outcomes (KDIGO), 2014, Clinical Practice Guideline for Lipid Management in CKD: Summary of Recommendation Statements and Clinical Approach to the Patient(56)
Use of Non-steroidal Mineralocorticoid Receptor Antagonist (ns-MRA) in patients with Type 2 diabetes, normokalaemia, and residual albuminuria despite other standard-of-care therapies.
Tools:
- Kidney Disease: Improving Global Outcomes (KDIGO), 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease(6)
- American Diabetes Association/Kidney Disease: Improving Global Outcomes (ADA/KDIGO), 2022, Diabetes Management in Chronic Kidney Disease: A Consensus Report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO)(52)
- American Diabetes Association, (ADA) 11. Chronic Kidney Disease and Risk Management: Standards of Care in Diabetes—2023(46)
Use of long-acting GLP-1 Receptor Agonist in patients with Type 2 diabetes not meeting glycemic targets despite first-line SGLT2 inhibitor ± metformin, ideally one with proven CVD benefit
Tools:
- Kidney Disease: Improving Global Outcomes (KDIGO), 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease(6)
- American Diabetes Association/Kidney Disease: Improving Global Outcomes (ADA/KDIGO), 2022, Diabetes Management in Chronic Kidney Disease: A Consensus Report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO)((52)
Medical nutrition therapy referral
Tools:
- Kidney Disease Quality Outcomes Initiative (KDOQI), Clinical Practice Guideline for Nutrition in CKD: 2020 Update(57)
NSAIDs avoidance
Tools:
- Am J Kidney Dis, 2020, NSAIDS in CKD: Are They Safe?, characterization of NSAID risks in patients with CKD(60)
Resources:
- J Am Pharm Assoc, 2015, Keeping kidneys safe: The pharmacist's role in NSAID avoidance in high-risk patients, overview of the role of the pharmacist in nonsteroidal anti-inflammatory drug (NSAID) avoidance in high-risk patients(58)
- Int J Health Care Qual Assur, 2017, Reducing inappropriate non-steroidal anti-inflammatory prescription in primary care patients with chronic kidney disease), addresses inappropriate NSAID prescribing in primary care patients with chronic kidney disease (CKD(59)
- Ann Fam Med, 2011, Nonsteroidal anti-inflammatory drug use among persons with chronic kidney disease in the United States, an overview of prescription and over-the-counter NSAID use by persons with CKD(61)
- Am J Nephrol, 2013, Healthy behaviors, risk factor control and awareness of chronic kidney disease, examines CKD self-recognition and its association with healthy behaviors and achievement of risk-reduction targets(62)
Use of a risk prediction model (i.e., the Kidney Failure Risk Equation)
Tools:
Resources:
- JAMA, 2011, A Predictive Model for Progression of Chronic Kidney Disease to Kidney Failure, describes how routine laboratory tests can be used in a model to accurately predict progression to kidney failure in patients with stage 3-5 CKD(63)
The Role of Testing in Kidney Disease Progression and Concomitant Risk for Cardiovascular Disease and Mortality is Underappreciated
"With regard to highlighting the importance of both eGFR and uACR screening in primary care, explaining the independent association with these markers for both kidney disease progression and cardiovascular disease risk is often a lightbulb moment for providers. Both are important, but there is a bit of confusion about the need for screening both parameters and additional education is often needed."
Joshua J. Neumiller, PharmD, CDCES, FASCP, FADCES
Washington State University
Change Package Faculty
Patients Often Share What They've Learned about Blood Pressure and CKD with Other Patients
"Bring the connection between blood pressure and kidney disease to the patients earlier and you’ll be surprised how many hang on to that, and they help each other in the group patient education sessions to kind of keep that in mind."
LaTasha Seliby Perkins, MD
Georgetown University School of Medicine
Change Package Faculty
There is Little Recognition that "Food is Medicine" When it Comes to CKD
"It’s amazing to me how few people have any knowledge about nutrition interventions that can be done to slow the progression of CKD."
Karen Greathouse, RD, CCTD
Fellow, National Kidney Foundation, University of Michigan Health System
Change Package Faculty
Prioritize social determinants of health and CKD care disparities within the program.
Tools:
- Centers for Medicare and Medicaid Services (CMS), 2023, USING Z CODES: The Social Determinants of Health (SDOH) Data Journey to Better Outcomes, a downloadable guide to using DSOH codes
- Centers for Medicare and Medicaid Services (CMS), 2021, Chronic Kidney Disease Disparities: Educational Guide for Primary Care, approaches to CKD identification, management, and patient-centered care
- American Academy of Family Physicians (AAFP), The EveryONE Project Toolkit, provides strategies to advance health equity within the clinician practice and community
Resources:
- NKF, Social Determinants of Kidney Disease, delineates relationship between kidney disease and SDOH.
- U.S. Department of Health and Human Services (HHS), Healthy People 2030, Social Determinants of Health, a detailed look at the conditions (SDOH) and their impacts to health, functioning and quality of life
- Centers for Disease Control and Prevention National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), 2022, Advancing Health Equity in Chronic Disease Prevention and Management, addresses strategies it has deployed to advance health equity.
Outcomes are Influenced by Understanding which Social Determinants of Health Impact the Patient and How They Do So
"Making that connection between the association of certain SDOH with outcomes–what’s related to access–what’s related to biology–and having a validated and consistent way of identifying connections–that’s the challenge and it might be different for different diseases."
Christine Chang, MD, MPH
Agency for Healthcare Research
Change Package Faculty
Characterize the impact of social determinants of health within geographies considered for your program.
Tools:
- Agency for Healthcare Research and Quality (AHRQ), SDOH Data and Analytics, provides access to various datasets and tools for SDOH analysis
- PRAPARE, Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences, The PRAPARE Screening Tool, a national standardized patient risk assessment tool to engage patients in assessing and addressing social drivers of health (SDOH).
- Confluence HL7.org, 2019, The Gravity Project, a collaborative public-private initiative launched in 2019 to develop consensus-driven data standards that support collection, use, and exchange of data to address the social determinants of health (SDOH).
- U.S. Department of Health and Human Services, National Institutes of Health, PhenX Social Determinants of Health (SDOH) Assessments Collection, catalog of recommended data measurement protocols to assess individual and structural factors that shape behaviors and health outcomes.
Resources:
- Social Interventions Research & Evaluation Network (Siren), 2022, SCREEN Report: State of the Science on Social Screening in Healthcare Settings, aims to improve health and health equity by advancing high quality research on health care sector strategies to improve social conditions(64)
- UNITE US, Cross-sector collaboration software to assist providers, health plans, government, and non-profits in identifying and delivering solutions and services that impact whole-person health.
Clearly communicate collaboration parameters between primary care and nephrology as determined by your Team.
Tools:
- U.S. Department of Veterans Affairs (VA), Chronic Kidney Disease Prevention, Early Recognition, and Management (VHA Directive 1053), Appendix A, VHA MEDICAL FACILITY PRIMARY CARE AND PATIENT ALIGNED CARE TEAM AND NEPHROLOGY CARE COORDINATION AGREEMENT NATIONALTEMPLATE(66)
- NKF, 2023, CKD Primary Care Management Algorithm, How to Manage CKD
Resources:
- U.S. Department of Veterans Affairs (VA), Chronic Kidney Disease Prevention, Early Recognition, and Management (VHA Directive 1053), Appendix A, VHA MEDICAL FACILITY PRIMARY CARE AND PATIENT ALIGNED CARE TEAM AND NEPHROLOGY CARE COORDINATION AGREEMENT NATIONALTEMPLATE(66)
- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)—Collaborate with the Nephrologist
- Duke Institute for Health Innovation, Improving Chronic Disease Management in Duke Primary Care: Building a Virtual Medical Neighborhood
Collaboration between Primary Care and Nephrology are Important to Outcomes because Primary Care Usually Extends Care Delivery Prior to Referral
"The majority of patients we see as nephrologists are first seen by primary care physicians, so we really depend on them to make critical decisions in terms of how care is delivered, because it impacts what happens in a patient’s life down the road."
Susanne Nicholas, MD, MPH, PhD
David Geffen School of Medicine at the University of California, Los Angeles
Change Package Faculty
Identify an implementation framework to assess implementation strategies/associated interventions and their outcomes.
Below are some widely used implementation frameworks for consideration.
Tools:
- RE-AIM (reach, effectiveness, adopt, implement, maintain), offers resources and tools to improve public health relevance and population health impact.
- Institute for Healthcare Improvement (IHI), offers downloadable tools to support Plan-Do-Study-Act (PDSA) initiatives to improve health care quality and safety.
- Agency for Healthcare Research and Quality (AHRQ), Plan-Do-Study-Act (PDSA), Directions and examples (utilizing a health literacy universal precautions toolkit).
- Implement Sci, 2022, The updated consolidated framework for implementation research based on user feedback., incorporates user responses to the original Consolidated Framework for Implementation Framework (CFIR) for an updated assessment tool.(70)
Resources:
- Implement Sci Commun, 2020, Ten recommendations for using implementation frameworks in research and practice, offers guidance for using implementation frameworks across the implementation process.(67)
- Fogarty International Center, National Institute of Health (NIH), 2023, NIH Toolkit Part 1: Implementation Science Methodologies and Frameworks, website overviews validated implementation science methodologies and frameworks.
- Implement Sci, 2019, Choosing implementation strategies to address contextual barriers: diversity in recommendations and future directions, reviews barriers and facilitators and which implementation strategies will best accommodate them.(68)
- Consolidated Framework for Implementation Research, overviews the foundational CFIR as a practical framework to help guide systematic assessment of potential barriers and facilitators which, in turn, can help guide tailoring of implementation strategies and needed adaptations, and/or explain outcomes.
References
- 6. Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work Group. KDIGO 2022 clinical practice guideline for diabetes management in chronic kidney disease. Kidney Int. 2022 Nov;102(5S):S1-S127.
- 19. Vassalotti JA, Centor, Turner BJ et al. Practical approach to detection and management of chronic kidney disease for the primary care clinician. Am J Med 2016 Feb;129(2):153-162.e7.
- 25. Inker LA, Astor BC, Fox CH et al. KDOQI US commentary on the 2012 KDIGO clinical practice guideline for the evaluation and management of CKD. Am J Kidney Dis. 2014;63(5):713-735.
- 39. Tuot DS and Powe NR. Chronic kidney disease in primary care: an opportunity for generalists. J Gen Intern Med 2011 Feb; 26(4):356–8.
- 40. Neumiller JJ, Shubrook JH, Manley T et al. Optimizing use of SGLT2 inhibitors and other evidence-based therapies to improve outcomes in patients with type 2 diabetes and chronic kidney disease: An opportunity for pharmacists. Am J Health Syst Pharm. 2022 Jan 1;79(1):e65-e70.
- 41. Strand MA, DiPietro MNA, Hall L et al. Pharmacy contributions to improved population health: expanding the public health roundtable. Prev Chronic Dis 2020 17:200350.
- 42. Norton JM, Kaltun A, Jurkovitz CT et al. Development and validation of a pragmatic electronic phenotype for CKD. Clin J Am Soc Nephrol. 2019 Sep 6;14(9):1306-1314.
- 43. Shang N, Khan A, Polubriaginof F et al. Medical records- based chronic kidney disease phenotype for clinical care and “big data” observational and genetic studies. npj Digital Medicine 2021 4:70.
- 44. van der Scheer JW, Woodward M, Ansari A et al. How to specify healthcare process improvements collaboratively using rapid, remote consensus-building: a framework and a case study of its application. BMC Med Res Methodol. 2021 21:103:1-16.
- 45. Moise N, Cene CW, Tabak RG et al. Leveraging implementation science for cardiovascular health equity: a scientific statement from the American Heart Association. Circulation. 2022;146:e260–e278.
- 46. ElSayed NA, Allepo G, Aroda VR et al. 11. Chronic kidney disease and risk management: standards of care in diabetes—2023. Diabetes Care 2023;46(Supplement_1):S191–S202.
- 47. Inker LA, Astor BC, Fox CH et al. KDOQI US Commentary on the 2012 KDIGO Clinical Practice Guideline for the Evaluation and Management of CKD. Am J Kidney Dis. 2014;63(5):713-735.
- 48. Handelsman Y, Anderson JE, Bakris G et al. DCRM Multispecialty Practice Recommendations for the management of diabetes, cardiorenal, and metabolic diseases. J Diabetes Complications. 2022;36(2):1-22.
- 49. Navaneethan SD, Zoungas S, Caramori ML et al. Diabetes management in chronic kidney disease: synopsis of the KDIGO 2022 clinical practice guideline update. Ann Intern Med. 2023;176:381-387.
- 50. KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney Int. 2021 99:S1–S87.
- 51. Taler SJ, Afarwal R, Bakris GL et al. KDOQI US commentary on the 2012 KDIGO clinical practice guideline for management of blood pressure in CKD. Am J Kidney Dis. 2013; Aug; 62(2):201–213.
- 52. de Boer IH, Khunti K, Sadusky T, et al. Diabetes management in chronic kidney disease: a consensus report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int. 2022 Nov;102(5):974-989.
- 53. Yau K, Dharia A, Alrowiyti I et al. Prescribing SGLT2 inhibitors in patients with CKD: expanding indications and practical considerations. Kidney Int Rep (2022) 7:1463–1476.
- 54. Tuttle KR, Brosius FC, Cavender, MA et al. SGLT2 inhibition for CKD and cardiovascular disease in type 2 diabetes: report of a scientific workshop sponsored by the National Kidney Foundation. Am J Kidney Dis. 2021 Jan;77(1):94-109.
- 55. Arnett DK, Blumenthal RS, Albert MA et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2019 Sep, 74 (10) e177–e232.
- 56. Wanner C, Tonelli M and the Kidney Disease: Improving Global Outcomes (KDIGO) Lipid Guideline Development Work Group Members KDIGO Clinical Practice Guideline for Lipid Management in CKD: summary of recommendation statements and clinical approach to the patient. Kidney Int. (2014) 85, 1303–1309.
- 57. Ikizler TA, Burrowes JD, Byham-Gray LD et al. KDOQI clinical practice guideline for nutrition in CKD: 2020. Am J Kidney Dis. 2020;76(3)(suppl 1):S1-S107.
- 58. Pai AB. Keeping kidneys safe: The pharmacist’s role in NSAID avoidance in high-risk patients. J Am Pharm Assoc (2003). 2015 Jan-Feb;55(1):e15-23.update.
- 59. Keohane DM, Dennehy T, Keohane KP et al. Reducing inappropriate non-steroidal anti-inflammatory prescription in primary care patients with chronic kidney disease. Int J Health Care Qual Assur. 2017 Aug 14;30(7):638-644.
- 60. Baker M and Perazella MA. NSAIDs in CKD: are they safe? Am J Kidney Dis. 2020 Oct;76(4):546-557.
- 61. Plantinga L, Grubbs V, Sarkar U et al. Nonsteroidal anti-inflammatory drug use among persons with chronic kidney disease in the United States. Ann Fam Med. 2011 Sep-Oct;9(5):423-30.
- 62. Tuot DS, Plantinga LC, Judd SE et al. Healthy behaviors, risk factor control and awareness of chronic kidney disease. Am J Nephrol (2013) 37 (2): 135–143.
- 63. Tangri N, Stevens LA, Griffith J et al. A predictive model for progression of chronic kidney disease to kidney failure. JAMA 2011 Apr 20;305(15):1553-9.
- 64. EH De Marchis, Brown E, Aceves BA et al. SCREEN Report: state of the science executive summary on social screening in healthcare settings. Summer 2022.
- 66. Chronic Kidney Disease Prevention, Early Recognition, and Management. Department of Veterans Affairs, Veterans Health Administration, Washington, DC 20420. March 17, 2020.
- 67. Moulin JC, Dickson KS, Stadnick NA et al. Ten recommendations for using implementation frameworks in research and practice. Implement Sci Commun. 2020 1:42.
- 68. Kaplan HC and Walsh KE. Context in implementation science. Pediatrics 2022 (149);Supplement 3.
- 70. Damschroder LJ, Reardon CM, Opra Widerquist MA et al. The updated consolidated framework for implementation research based on user feedback. Implement Sci. 2022 Oct 29: 2-16.