Improving Chronic Disease Management with Pieces (ICD-Pieces)

描述（由申请人提供）：患有慢性肾脏疾病（CKD）、糖尿病和高血压的患者数量不断增加，这是一项公共卫生挑战。CKD、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3种慢性疾病。在过去的二十年中，美国成人慢性肾病的患病率从10%增加到14%，糖尿病和高血压是慢性肾病和终末期肾病的两个主要原因。在CKD，糖尿病和高血压的有效治疗方法的识别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存在重大差距。我们最近在帕克兰健康和医院系统为主要少数民族的CKD患者实施了一个合作的初级保健和肾脏病护理模型，使用一种新的技术平台（Pieces-帕克兰智能电子协调和评估系统），使我们能够利用电子健康记录（EHR）的信息，促进在社区的初级保健实践和医疗家中实施CKD护理。在一项由NIDDK支持的研究中，我们已经观察到通过协作护理模式在血压控制方面的改善，该模式使用Pieces来识别CKD患者并协助实施推荐的做法。我们还使用Pieces成功地开发了各种风险预测模型，用于合作大型医疗保健系统的再入院和死亡。我们现在提议在4个大型卫生保健系统中进行一项随机实用试验，改善慢性疾病碎片管理（ICD-Pieces），以测试我们对多病患者的护理模式。主要假设是CKD、高血压和糖尿病患者接受由新型信息技术（Pieces）加强的初级保健-亚专科护理合作模式的护理，将比接受标准医疗护理的患者住院、再入院、心血管事件和死亡更少。在计划阶段（UH2），我们将建立合作实验室，并在所有参与研究的地点完成准备工作。在实施阶段（UH3），我们将在合作实验室的4个大型卫生保健系统中进行随机临床试验。我们的试验是务实的、随机的、严格的对照，并测试了几种被接受的、特征明确的干预措施的实施情况，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。我们的研究明确定义了里程碑。4个参与的大型卫生保健系统有不同的组织结构，使用不同的电子病历，服务非常不同的患者群体。我们期望我们的研究结果将为未来的临床试验提供一个框架，并促进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.