Multidisciplinary electronic consultation to improve evidence-based care for patients with diabetic kidney disease

项目摘要/摘要 糖尿病肾病(DKD)是终末期肾病(ESKD)的主要病因。尽管有证据表明 钠-葡萄糖共转运体-2抑制剂(SGLT2i)和肾素和血管紧张素系统抑制剂(RAASI)可以 降低糖尿病患者ESKD的风险，处方率仍然很低。此R03提案具有响应性 TO SEN NOT-HS-19-011：实现高价值医疗系统的医疗服务研究优先事项 其中特别提到了“转变肾脏护理”和“重塑初级保健”。这项研究的目的是 是最后确定和评估多学科项目的执行情况和初步成效 糖尿病肾脏疾病计划(MDKDP)是蒙特菲奥雷制定的一项人口健康战略，以 确保对DKD患者的循证护理。MDKDP旨在克服已知的障碍 初级保健提供者(PCP)为高危DKD患者开RAASI和SGLT2i。MDKDP是 由三个实施战略组成：1)高危DKD(High-Risk DKD)患者的仪表盘 仪表板)允许主动瞄准未接受循证治疗的患者，2) 内分泌学家、肾病学家和儿科医生之间的多学科合作，以及3)使用一种新的 人口健康战略，内分泌学家和肾病学家使用 为高危DKD仪表板上发现治疗差距的患者提供电子会诊(电子会诊)。 MDKDP电子咨询的内容将为个别患者定制，并包括以下建议 使用RAASI和/或SGLT2i以及修改目前开出的糖尿病和高血压药物。 MDKDP电子会诊后有三个潜在的结果：1)PCP引发的治疗变化，2)PCP 通过患者与专科团队的预约请求共同管理，或3)不更改。具体的 本提案的目的是：1)通过确定可能影响执行《千年发展目标》的因素，最终确定千年发展目标 千年发展目标和修改执行战略的可行建议，以及2)评估 采纳性、可接受性、适当性和可行性的实施结果，并进行初步评估 有效性定义为PCP发起的SGLT2i和/或RAASI处方或联合 管理层。我们将与医生利益相关者一起对焦点小组进行定性分析，以最终确定 MDKDP，对20对PCP-患者对MDKDP进行试点测试，并对试点试验的访谈进行定性分析 参与者。此R03将允许研究团队严格评估MDKDP，以评估其 成功地为进展为ESKD的高危人群实施了循证治疗。 根据结果，研究小组将准备一个未来的大型随机对照试验，旨在扩大干预和 评估患者预后，包括血压、血红蛋白A1C和DKD进展。MDKDP是 可概括为美国机构在DKD的循证治疗和电子邮件的使用方面存在差距 人口健康管理的咨询可以适用于其他高收益的循证实践。

PROJECT SUMMARY/ABSTRACT Diabetic kidney disease (DKD) is the leading cause of end stage kidney disease (ESKD). Despite evidence that sodium-glucose cotransporter-2 inhibitors (SGLT2i) and renin and angiotensin system inhibitors (RAASi) can reduce of risk of ESKD in patients with diabetes, prescription rates remain low. This R03 proposal is responsive to SEN NOT-HS-19-011: Health Services Research Priorities for Achieving a High Value Healthcare System which specifically addresses “transforming kidney care” and “reinventing primary care.” The goal of this study is to finalize and assess the implementation and preliminary effectiveness of the Multidisciplinary Diabetic Kidney Disease Program (MDKDP), a population health strategy developed at Montefiore, to assure evidence-based care for patients with DKD. MDKDP is designed to overcome known barriers to prescribing RAASi and SGLT2i by primary care providers (PCPs) for patients with high-risk DKD. MDKDP is composed of three implementation strategies: 1) a dashboard of patients with high-risk DKD (High-risk DKD Dashboard) allowing the proactive targeting of patients not receiving evidence-based treatment, 2) multidisciplinary collaboration between endocrinologists, nephrologists and PCPs, and 3) use of a novel population health strategy where endocrinologists and nephrologists initiate contact with PCPs using an electronic consultation (e-consult) for patients with treatment gaps identified on the High-risk DKD Dashboard. The content of the MDKDP e-consult will be customized for individual patients and include recommendations for use of RAASi and/or SGLT2i and modification of currently prescribed diabetes and hypertension medications. There are three potential outcomes following a MDKDP e-consult: 1) PCP-initiated change in treatment, 2) PCP request for co-management through a patient appointment with the specialist team or 3) no changes. The specific aims of this proposal are 1) to finalize MDKDP by identifying the factors which may affect the implementation of MDKDP and actionable recommendations for modifying the implementation strategies and 2) to assess the implementation outcomes of adoption, acceptability, appropriateness and feasibility and evaluate preliminary effectiveness defined as PCP-initiated change in SGLT2i and/or RAASi prescription or request for co- management. We will perform qualitative analysis of focus groups with physician stakeholders to finalize MDKDP, pilot test MDKDP for 20 PCP-patient pairs, and perform qualitative analysis of interviews with pilot trial participants. This R03 will allow the study team to rigorously evaluate MDKDP to assess the degree to which it is successful in implementing evidence-based treatments for a population at high risk for progression to ESKD. Based on outcomes, the research team will prepare a future, large RCT designed to scale the intervention and evaluate patient outcomes including blood pressure, hemoglobin A1C, and DKD progression. MDKDP is generalizable to U.S. institutions experiencing gaps in evidence-based treatments for DKD and the use of e- consults for population health management can be adapted to other high yield evidence-based practices.