Nudging nephrologists in cardiovascular risk assessment and management in glomerular diseases treated with immunosuppressants: an implementation study

Background: Glomerulonephritis and its treatment may be associated with cardiometabolic disease, so optimizing glycemic and lipid control is important to mitigate cardiovascular risk. We aimed to evaluate the impact of an electronic medical records (EMR)-based physician prompt on glycemic and lipid management among older adults with glomerulonephritis receiving immunosuppressive therapy. Methods: This was a single-center implementation study with a pre-post design. We included adults ≥40 years old with active glomerulonephritis treated with immunosuppressants who received the physician prompt between July 2022 and June 2024. Data at 6-monthly intervals were obtained from the EMR. We compared the prevalence of glycemic and lipid evaluation during follow-up visits before and after the intervention using mixed effects logistic regression models. Results: A total of 192 patients [median age 58 (interquartile range: 48, 69) years] with 859 visits were included: 474 visits prior to the intervention and 385 visits after its implementation. The most frequent causes of glomerulonephritis were lupus nephritis (26.9%), IgA nephropathy (20.4%), and ANCA-associated vasculitis (15.7%). Glycemic evaluation was performed at 51.7% and 69.6% of follow-up visits before and after intervention, respectively. Glycemic evaluation was significantly more likely at post- compared with pre-intervention visits [OR 2.42 (95% CI: 1.73, 3.36)] after accounting for patients and physicians as random effects, and after adjusting for age, sex, kidney function, follow-up clinic type and duration and RAS blocker and statin therapy: OR 2.38 (95% CI: 1.69, 3.38)]. Fasting lipid was performed at 43.7% and 42.9% of follow-up visits before and after intervention, respectively, and was not different pre- and post-intervention. Conclusions: A physician-directed nudge significantly increased glycemic evaluation but not lipid evaluation in older patients with glomerulonephritis treated with immunosuppressants.