Improving CKD Detection and Care in a High Risk Underserved Population

描述（由申请人提供）：慢性肾脏疾病（CKD）患者数量的增长是一个公共卫生挑战。一些干预措施已被证明对改善CKD患者的预后有效，但许多患者不接受这些治疗。对于某些少数民族和服务不足的人群，如何治疗CKD的知识进步与最佳护理的实施之间的差距尤其大。该提案的主要目标是改善所有CKD患者的护理，并制定可能在高风险服务不足人群中特别有效的策略。我们的主要教学医院，帕克兰健康和医院系统（PHHS），照顾达拉斯县服务不足的人群，主要服务于非洲裔美国人和西班牙裔人口。公共卫生保健系统有一个初级保健诊所网络，分布在整个社区，并被指定为医疗之家。PHHS拥有一个完全可操作的it支持项目，即Parkland智能电子协调和评估系统（PIECES），该系统有助于利用电子病历在我们的患者群体中实施、协调和监测基于证据的干预措施。该建议的主要假设是，一种新的联合初级保健-肾脏科保健模式将改善慢性肾脏疾病患者CKD和CV并发症进展危险因素的临床管理。我们还建议应用一种新型的健康信息技术平台，可以在非裔美国人和西班牙裔患者群体中更早地发现CKD，并促进CKD护理和肾脏替代治疗的准备。第一个具体目标是提高在PHHS服务的高风险主要少数人群中CKD的检测。第二个具体目标是实施被证明可以减缓CKD进展和治疗相关疾病的干预措施。第三个具体目标是使患者为最佳开始肾脏替代治疗做好准备，包括为移植做准备，如果需要透析，及时选择方式，通路放置和避免临时中心静脉导管。成功应用这种结合了新的健康信息技术的初级保健/肾脏学合作护理模式，不仅可以改善我们机构的少数患者的护理，还可以改善美国所有CKD患者的护理。

DESCRIPTION (provided by applicant): The growing number of patients with chronic kidney disease (CKD) is a public health challenge. Several interventions have been proven to be effective in improving outcomes for patients with CKD, but many patients do not receive these therapies. The gap between advances in knowledge of how to treat CKD and implementation of optimal care is especially large for members of certain ethnic and racial minorities and underserved populations. The main goal of this proposal is to improve the care of all patients with CKD and to develop strategies that may prove to be particularly effective in high risk underserved populations. Our main teaching hospital, Parkland Health and Hospital Systems (PHHS), cares for the underserved in Dallas County and serves a predominantly African-American and Hispanic population. PHHS has a network of primary care clinics distributed throughout the community and designated as Medical Homes. PHHS has a fully operational IT-enabled program, the Parkland Intelligent e- Coordination and Evaluation System (PIECES), that facilitates harnessing the electronic medical record to implement, coordinate and monitor evidence-based interventions in our patient population. The main hypothesis of this proposal is that a new model of joint primary care-nephrology care will improve clinical management of risk factors for progression of CKD and CV complications in patients with chronic kidney disease. We also propose that the application of a novel health information technology platform will allow earlier detection of CKD in African-American and Hispanic patient populations and facilitate CKD care and preparation for renal replacement therapy. The first specific aim is to improve detection of CKD in the high risk predominantly minority population served at PHHS. The second specific aim is to implement interventions proven to slow the progression of CKD and treat associated conditions. The third specific aim is to prepare patients for optimal initiation o renal replacement therapy including preparation for transplantation and if dialysis is needed, timely modality selection, access placement and avoiding temporary central venous catheters. Successful application of this collaborative primary care/nephrology model of care which incorporates new health information technology has the potential to improve the care not only for minority patients in our institution for all CKD patients in the United States. PUBLIC HEALTH RELEVANCE: Chronic kidney disease (CKD) is a common medical problem that leads to higher mortality, hospitalizations, and costs. Many patients do not receive treatments proven to help slow the progression of kidney disease and its complications. This study is directed to improving the care of CKD patients especially for those in minority populations that are at the highest risk.