# PopulAtioN health management to OPTImize Care in CKD (PANOPTIC-CKD)

> **NIH NIH R01** · VANDERBILT UNIVERSITY MEDICAL CENTER · 2022 · $602,694

## Abstract

Millions of adults have chronic kidney disease (CKD), leading to substantial morbidity, mortality and
health care costs. These effects are concentrated in patients with high-risk disease. Several provider- and
system-level barriers lead to well-described gaps in care for these patients, contributing to poor outcomes.
Given the growing CKD population, the relative dearth of nephrologists, and the fragmented care that high-risk
patients receive, novel tools are needed to improve the quality and safety of CKD care and clinical outcomes.
 Population health management (PHM) improves health by aggregating and analyzing data across a
population to drive consistent, evidence-based care. CKD PHM using electronic health records (EHRs) can be
a sustainable strategy to overcome physician- and system-level barriers. EHR-based PHM could improve the
identification of patients with high-risk CKD; increase the use of evidence-based, widely available, and cost-
effective interventions; and enhance medication safety. We have developed the tools needed to implement and
examine the impact of an EHR-based PHM intervention. Our multidisciplinary team has constructed a dynamic
CKD registry containing real-time data and embedded metrics for identifying high-risk CKD using validated
risk-prediction models, reviewing medication exposures, and monitoring processes of care. We have
successfully leveraged this tool to pilot an EHR-based PHM intervention that targets the timely detection of
high-risk CKD, the implementation of remote nephrology guidance to improve evidence-based CKD care, and
the provision of medication safety reviews and standardized CKD patient education.
 The overarching aim of this proposal is to test the effectiveness of a multifaceted EHR-based PHM
intervention to improve the delivery of evidence-based CKD care in high-risk patients. The University of
Pittsburgh's extensive PCP network offers the ideal setting to evaluate the intervention with 330 PCPs caring
for over 480,000 patients while using the Epic EHR. We will perform a 42-month pragmatic, cluster randomized
controlled trial in ~1,700 patients with high-risk CKD managed by their PCPs to determine whether EHR-based
PHM improves key processes of care and clinical outcomes. We hypothesize that EHR-based PHM will
improve hypertension control, use of renin angiotensin aldosterone system inhibitors in patients with
albuminuria, and avoidance of renally contraindicated medications (Aim 1) and delay CKD progression (Aim 2).
This novel intervention benefits from customization based on PCP stakeholder feedback, executive level
support from the medical center and health plan, and enthusiastic support from PCPs. This study directly
responds to calls from national primary care organizations to use EHRs to implement PHM while limiting the
PCP burden. CKD PHM may provide a sustainable, resourceful approach to improving CKD care, outcomes,
and safety. In addition, our pragmatic cluster RCT will produce code for ...

## Key facts

- **NIH application ID:** 10453753
- **Project number:** 5R01DK116957-05
- **Recipient organization:** VANDERBILT UNIVERSITY MEDICAL CENTER
- **Principal Investigator:** Khaled A Abdel-Kader
- **Activity code:** R01 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2022
- **Award amount:** $602,694
- **Award type:** 5
- **Project period:** 2018-08-01 → 2024-07-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10453753

## Citation

> US National Institutes of Health, RePORTER application 10453753, PopulAtioN health management to OPTImize Care in CKD (PANOPTIC-CKD) (5R01DK116957-05). Retrieved via AI Analytics 2026-05-24 from https://api.ai-analytics.org/grant/nih/10453753. Licensed CC0.

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