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: 10515630
• 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/10515630
• 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; Recommendation; Renin-Angiotensin System; Renin-Angiotensin-Aldosterone System; Reporting; Research Methodology; Research Priority; Risk; Risk Reduction; 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; care costs; 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 care provider; 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：退伍军人中中度至重度慢性肾脏病（CKD）的患病率比普通人群高70%。 普通民众。非透析依赖型CKD人群护理的年度成本增加至180亿美元 2016年，为退伍军人管理局。血管紧张素转换酶抑制剂（ACEI）和血管紧张素II 受体阻滞剂（ARB）被认为是CKD患者的标准治疗，因为它们可以改善心血管疾病 结果和延迟进展到终末期肾病。在患有糖尿病和CKD的退伍军人中， 66%的患者使用ACEI或ARB，各机构之间差异显著。在未接受ACEI或 ARB，目前尚不清楚他们是否开始使用这些药物，开始但因不良事件而停止，或 从未开始使用ACEI或ARB，例如由于临床惰性。ACEI/ARB停药与 增加了透析的需要和更高的死亡风险。在这份提案中，我们计划了解 使用结构化数据集，将ACEI/ARB使用不足归因于副作用与临床惰性， 非结构化的提供者文本注释，以及启动和重新启动（中断后）的障碍 ACEI/ARB。基于这些学习，我们建议在患者对齐护理中进行试点测试 ACTs将帮助临床医生在CKD患者中启动或重新启动ACEI/ARB治疗。 重要性：成功推行建议的研究，有助我们（a）了解 缺乏ACEI或ARB启动和它们的中止（B）成功地开发、完善和试点试验a 在CKD人群中优化ACEI/ARB使用的沟通辅助。这些可以减少肾脏疾病 进展，改善心血管结局和VA系统的潜在成本节约。 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ACEI或ARBS未充分利用的全部背景。此外，我们利用创新 定性技术和人为因素是研究和解决护理中这一重要差距的最佳做法。 目的1：研究CKD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 与两个三级医疗机构的PACT提供者和患者及其社区门诊患者的访谈 进一步了解缺乏ACEI或ARB启动或停止的原因 慢性肾脏病退伍军人中。根据这些访谈，我们将完善一个简洁的沟通援助， PACT提供者，使他们能够有效地在CKD患者中启动和/或重新启动ACEI/ARB （包括先前有副作用的患者）。目标3：对临床医生的沟通辅助工具进行试点测试，以提高 开始ACEI或ARB治疗，或因不良事件停药后重新开始ACEI或ARB治疗。 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，以实现目标灵敏度， 与手动病历审查相比，特异性>90%，以评估缺乏启动/重新启动的原因 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患者缺乏开始或重新开始ACEI或ARB治疗。然后，我们将改进 在目标3的试点试验期间使用的通信辅助设备（使用人为因素专家）。目标3： 进行试点试验。干预地点的所有PACT提供者都将获得沟通援助以改善 开始ACEI/ARB治疗或因不良事件停药后重新开始ACEI/ARB治疗。在 通常的护理站点，PACT提供者将只收到他们的CKD患者比例的季度报告， ACEI/ARB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：如果目标3的试点研究取得成功，我们将致力于在全系统实施 我们在整个VISN中提供沟通援助，以改善CKD退伍军人中ACEI或ARB的使用。