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

项目总结/摘要 糖尿病肾病（DKD）是终末期肾病（ESKD）的主要原因。尽管有证据表明 钠-葡萄糖协同转运蛋白-2抑制剂（SGLT 2 i）和肾素和血管紧张素系统抑制剂（RAASi）可 降低糖尿病患者ESKD的风险，处方率仍然很低。本R 03提案是响应性的 SEN NOT-HS-19-011：实现高价值医疗保健系统的卫生服务研究优先事项 它专门针对“肾脏护理的转变”和“重塑初级保健”。本研究的目的 最后确定和评估多学科计划的实施情况和初步成效， 糖尿病肾病计划（MDKDP）是Montefiore制定的一项人口健康战略， 确保DKD患者的循证护理。MDKDP旨在克服已知的障碍， 由初级保健提供者（PCP）为高风险DKD患者开具RAASi和SGLT 2 i处方。MDKDP是 由三个实施策略组成：1）高风险DKD患者仪表板（高风险DKD 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PCP之间的多学科合作，以及3）使用一种新的 人群健康策略，内分泌学家和肾病学家使用 针对在高风险DKD仪表板上确定存在治疗缺口的患者的电子咨询（e-consult）。 MDKDP电子咨询的内容将针对个体患者进行定制，包括以下建议： 使用RAASi和/或SGLT 2 i，并修改目前处方的糖尿病和高血压药物。 MDKDP电子咨询后有三种潜在结果：1）PCP引发的治疗变化，2）PCP 通过与专家团队的患者预约请求共同管理或3）没有变化。具体 本提案的目的是：1）通过确定可能影响实施的因素， MDKDP和修改实施战略的可操作建议; 2）评估 采用、可接受性、适当性和可行性的实施结果，并评估初步 有效性定义为PCP发起的SGLT 2 i和/或RAASi处方变更或共同 管理我们将与医生利益相关者对焦点小组进行定性分析， MDKDP，对20个PCP-患者对进行MDKDP预试验，并对预试验的访谈进行定性分析 参与者本R 03将允许研究团队严格评估MDKDP，以评估其 成功地对ESKD进展高风险人群实施循证治疗。 根据结果，研究小组将准备一个未来的大型RCT，旨在扩大干预， 评估患者结局，包括血压、血红蛋白A1 C和DKD进展。MDKDP是 可推广到在DKD循证治疗和使用电子治疗方面存在差距的美国机构， 人口健康管理咨询可适用于其他高产出循证做法。

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.