Improving Chronic Disease Management with Pieces (ICD-Pieces)

描述(申请人提供)：越来越多的患者患有慢性肾脏疾病(CKD)、糖尿病和高血压，这是一个公共卫生挑战。慢性肾脏病、糖尿病和高血压是增加发病率、死亡率、资源利用率和成本的三种慢性疾病(CMC)。在美国成年人中，CKD的患病率在过去20年中从10%上升到14%，糖尿病和高血压是CKD和终末期肾脏疾病的两大原因。在确定治疗慢性肾脏病、糖尿病和高血压的有效治疗方法方面取得了重要进展，但在将这些治疗方法转化为临床实践方面仍有很大差距。我们最近在Parkland Health and Hospital System为以少数族裔为主的CKD患者实施了协作初级保健和肾脏疾病护理模式，使用了一个新的技术平台(PICES-Parkland智能电子协调和评估系统)，该平台允许我们利用电子健康记录(EHR)中的信息来促进社区初级保健实践和医疗机构中CKD护理的实施。在NIDDK支持的一项研究中，我们已经观察到通过协作护理模式在BP控制方面的改善，使用PICES来识别CKD患者并帮助实施推荐的做法。我们还使用PICES成功地开发了协作大型医疗保健系统中再入院和死亡的各种风险预测模型。我们现在建议在4个大型医疗保健系统中进行一项随机、务实的试验，以改善慢性病管理(ICD-PICES)，以测试我们为多病患者提供护理的模式。主要假设是，与接受标准医疗护理的患者相比，接受初级保健-由新型信息技术(PICES)增强的初级保健-专科护理协作模式护理的CKD、高血压和糖尿病患者的住院、再入院、心血管事件和死亡人数将较少。在规划阶段(UH2)，我们将在所有参与研究的地点建立协作并完成准备工作。在实施阶段(UH3)，我们将在合作实验室的4个大型医疗保健系统中进行随机临床试验和务实试验。我们的试验是务实和随机的，严格控制和测试几种被接受的和特征良好的干预措施的实施，这些干预措施将被协调并广泛应用于CKD、高血压和糖尿病患者，以评估临床相关的结果。我们的研究已经明确界定了里程碑。四个参与的大型医疗保健系统有不同的组织结构，使用不同的电子病历，并为非常不同的患者群体提供服务。我们预计，我们的研究结果将为未来的临床试验提供一个框架，并推动对患有多种慢性疾病的患者的护理。

DESCRIPTION (provided by applicant): The growing number of patients who have chronic kidney disease (CKD), diabetes and hypertension is a public health challenge. CKD, diabetes and hypertension are 3 chronic medical conditions (CMCs) that increase morbidity, mortality, resource utilization and costs. Among adults in the United States the prevalence of CKD has increased from 10 to 14% over the past two decades and diabetes and hypertension are the 2 leading causes of CKD and end-stage renal disease. Important progress in identification of effective treatments for CKD, diabetes and hypertension has been made but there is a significant gap in translating these treatments to clinical practice. We have recently implemented a collaboratory primary care and nephrology care model at Parkland Health and Hospital System for patients with CKD in a predominantly minority population using a novel technology platform (Pieces- Parkland intelligent e-coordination and evaluation system) that allows us to leverage information from the electronic health record (EHR) to facilitate implementation of CKD care within primary care practices and medical homes in the community. In a study supported by NIDDK we are already observing improvements in BP control with a collaborative care model using Pieces to identify people with CKD and assist implementing recommended practices. We have also used Pieces to successfully develop various risk prediction models for readmissions and deaths in collaborating large health care systems. We now propose a randomized pragmatic trial, Improving Chronic Disease Management with Pieces (ICD-Pieces), in 4 large health care systems to test our model of care for patients with multimorbidity. The main hypothesis is that patients with CKD, hypertension and diabetes who receive care with a collaborative model of primary care-subspecialty care enhanced by novel information technology (Pieces) will have fewer hospitalizations, readmissions, CV events and deaths than patients receiving standard medical care. During the planning phase (UH2) we will establish the collaboratory and complete preparations at all participating sites for the study. In the implementation phase (UH3) we will conduct the randomized clinical trial pragmatic trial across the 4 large health care systems in the collaboratory. Our trial is pragmatic and randomized with rigorous controls and tests the implementation of several accepted and well-characterized interventions which will be coordinated and applied broadly to patients with CKD, hypertension and diabetes to evaluate clinically relevant outcomes. Our study has clearly defined milestones. The 4 participating large health care systems have different organizational structures, utilize different EHR and serve very different patient populations. We anticipate that findings from our study will provide a framework for future clinical trials and to advance the care of patients with multiple chronic medical conditions.