Optimizing Renin Angiotensin System Blocker Use among Veterans with Kidney Disease

优化肾素血管紧张素系统阻滞剂在患有肾脏疾病的退伍军人中的使用

• 批准号: 10229343
• 负责人: Sankar Dass Navaneethan
• 金额: --
• 依托单位: MICHAEL E DEBAKEY VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2020
• 资助国家: 美国
• 起止时间: 2020-10-01 至 2025-09-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10229343
• 关键词: Address; Adverse event; Albuminuria; Algorithms; Ambulatory Care Facilities; Angioneurotic Edema; Angiotensin II Receptor; Angiotensin-Converting Enzyme Inhibitors; Antihypertensive Agents; Cardiovascular Diseases; Cardiovascular system; Caring; Cessation of life; Chronic Disease; Chronic Kidney Failure; Clinical; Cognitive; Communities; Cost Analysis; Cost Savings; Coughing; Creatinine; Data Set; Department of Defense; Diabetes Mellitus; Dialysis procedure; Diet Modification; Disease Progression; Diuretics; Dose; End stage renal failure; Event; General Population; Guidelines; Health Services Research; Health care facility; Healthcare Systems; High Prevalence; Human; Hypertension; Hypotension; Informatics; Information Retrieval; Intervention; Interview; Kidney Diseases; Learning; Life; Manuals; Medical center; Methodology; Morbidity - disease rate; Myocardial Ischemia; Natural Language Processing; New Agents; Outcome; Patients; Pharmaceutical Preparations; Physiological; Pilot Projects; Population; Potassium; Prevalence; Provider; Qualitative Research; Quality of life; Renin-Angiotensin System; Renin-Angiotensin-Aldosterone System; Reporting; Research Methodology; Research Priority; Risk; Savings; Secondary to; Sensitivity and Specificity; Serum; Site; Structure; System; Techniques; Testing; Text; Time; Training; Treatment Side Effects; United States; United States Department of Veterans Affairs; Variant; Veterans; Veterans Health Administration; base; care costs; care providers; communication aid; cost; cost effectiveness; design; diabetic; follow-up; high risk; high risk population; hyperkalemia; improved; inhibitor; innovation; mortality; mortality risk; non-diabetic; novel; pilot test; pilot trial; point of care; primary outcome; provider behavior; side effect; sound; standard of care; structured data; tertiary care; treatment as usual; unstructured data

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.

背景：退伍军人中重度慢性肾脏疾病(CKD)的患病率比退伍军人高70% 普通民众。年，非透析依赖型慢性肾脏病人群护理的年成本增加到180亿美元 2016财年退伍军人管理局。血管紧张素转换酶抑制剂(ACEI)与血管紧张素II 受体阻滞剂(ARB)被认为是CKD患者的标准护理，因为它们改善了心血管 结果和延缓进展到终末期肾病。在患有糖尿病和慢性肾脏病的退伍军人中，只有 66%的人服用ACEI或ARB，不同设施之间存在显著差异。在没有接受ACEI或 ARB，尚不清楚它们是在这些药物上启动的，启动后因不良事件而停止，还是 从未开始使用ACEI或ARB，例如由于临床惰性。ACEI/ARB中断与 需要更多的透析和更高的死亡率。在这份提案中，我们计划了解 使用结构化数据集将ACEI/ARB的使用不足归因于副作用和临床惰性 非结构化提供商文本注释，以及启动和重新启动(在停止后)的障碍 ACEI/ARB.基于这些学习，我们建议在患者定向护理中试行一种沟通辅助工具。 团队(PACT)，将协助临床医生启动或重新启动CKD患者的ACEI/ARB治疗。 意义：拟议研究的成功实施将有助于我们(A)了解 缺乏ACEI或ARB的启动和停止(B)成功地开发、完善和试行试验a 在CKD人群中优化ACEI/ARB使用的沟通辅助工具。这些可以减少肾脏疾病。 进展、心血管结果的改善以及VA系统潜在的成本节约。 创新：该项目利用自然语言处理的结构化和非结构化数据 (NLP)了解未充分利用ACEI或ARB的全部背景。此外，我们利用创新的 研究和解决护理中的这一重要差距，定性技术和人为因素优于实践。 目的1：探讨慢性肾脏病患者缺乏ACEI或ARB治疗的原因 基于结构化数据和使用NLP的自动信息提取。目标2：进行半结构化 与两家三级医疗机构的PACT提供者和患者及其社区门诊患者进行访谈 诊所(CBOC)进一步了解没有启动或停止ACEI或ARB的原因 在患有CKD的退伍军人中。在这些采访的基础上，我们将提炼出有针对性的简明沟通辅助工具 走向PACT提供者，使他们能够有效地启动和/或重新启动CKD患者的ACEI/ARB (包括那些先前有副作用的)。目的3：试行一种通讯辅助设备，以供临床医生改进 启动ACEI或ARB，或在因不良事件而停止后重新启动ACEI或ARB。 方法：对于目标1，我们将使用VA结构化数据集识别CKD患者，并随机 将它们划分为训练集和测试集。然后我们将训练我们的NLP系统以实现目标敏感度和 与手动图表检查相比，评估缺乏启动/重新启动的原因的特异度为90% ACEI/ARB.对于目标2，我们将进行半结构化的患者和提供者访谈，以了解障碍 CKD患者缺乏ACEI或ARB的启动或再启动。然后，我们将细化 在目标3的试点试验期间使用的通信辅助工具(使用人的因素专家)。对于目标3，我们将 进行试点试验。干预现场的所有PACT提供者都将获得沟通援助，以改善 启动ACEI/ARB或在因不良事件中断后重新启动ACEI/ARB。在 常规护理网站，PACT提供者将只收到其CKD患者的季度报告比例，而不是 在ACEI/ARB上。我们的主要结果是接受ACEI/ARB治疗的CKD患者比例的变化。 下一步：如果我们在目标3的试点研究成功，那么我们将致力于在全系统范围内实施 我们的沟通辅助在我们的VISN中，以改善患有CKD的退伍军人的ACEI或ARB使用。