Closing the Cardio-Renal Preventive Treatment Gap Among Patients with Type 2 Diabetes Mellitus and Chronic Kidney Disease: An Implementation Science Approach

项目摘要/摘要 患有2型糖尿病(T2 DM)和慢性肾脏疾病(CKD)的人有极高的风险 心血管疾病(CVD)。然而，它们并不是循证心脏肾脏的最佳处方。 可以显著降低此类风险的预防性治疗。这些疗法，包括血管紧张素- 转换酶抑制剂/血管紧张素受体阻滞剂(ACEI/ARB)、胰高血糖素样肽-1受体 激动剂(GLP1)和钠-葡萄糖协同转运体2抑制剂(SGLT2i)显著降低心血管疾病风险和 CKD进展的风险。因此，他们的最佳处方可以显著减少心血管疾病的负担 2型糖尿病和慢性肾脏病患者。 在奖项的指导阶段，拟议的研究将调查主要因素 T2 DM和CKD患者心肾预防治疗处方不足的原因。 为此，我们将进行定量与定性相结合的混合方法研究。 探险。具体地说，在目标1中，我们将利用超过150万名T2 DM患者的数据集 退伍军人事务部(VA)系统识别心肾预防处方的多层次预测因素 治疗。在目标2中，我们将与患者和提供者进行焦点小组，以定性地探索背景 心肾预防治疗处方不足的决定因素。 在奖项的独立阶段(目标3)，我们将利用目标1和目标2的调查结果来 实施旨在提高初级保健提供者知识和自我效能的教育干预 关于在一家医疗机构进行的心肾预防治疗。教育的组成部分 干预措施包括：1)教育工具包，包括信息手册、情况说明书/信息图表，以及 诊所使用的宣传性海报；2)初级保健提供者的拥护者，将作为参考 关于心肾预防治疗处方的提供者；以及3)跨学科的病例会议 关于心肾疗法的适当处方。我们将评估初级保健的变化 干预前后服务提供者的知识和自我效能感，比较干预前后服务提供者知识和自我效能感的变化 采用“被动”控制医疗设施的心肾预防治疗处方。 完成执行科学和混合方法方面的拟议研究和培训 研究将有助于确立Lamprea Montealegre博士在 心血管疾病流行病学和实施科学的交叉。特别是，新的一套技能 实施科学将使Lamprea Montealegre博士能够领导关于心血管疾病的研究和临床计划 通过系统地检测和治疗慢性肾脏病进行预防，并成为全国领先的 预防性的心肾护理。

Project Summary/Abstract Individuals with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD) have an extremely high risk of cardiovascular disease (CVD). However, they are not optimally prescribed evidence-based cardio-renal preventive therapies that could considerably reduce such risk. These therapies, which include angiotensin- converting enzyme inhibitors/angiotensin-receptor blockers (ACEI/ARB), glucagon-like peptide-1 receptor agonists (GLP1) and sodium-glucose co-transporter 2 inhibitors (SGLT2i), substantially lower CVD risk and the risk of CKD progression. Thus, their optimal prescription could lead to marked reductions in the CVD burden of patients with T2DM and CKD. In the mentored phase of the award, the proposed research will investigate the major factors accounting for the under-prescription of cardio-renal preventive therapies among patients with T2DM and CKD. To accomplish this, we will conduct mixed-methods research combining quantitative analyses with qualitative explorations. Specifically, in Aim 1 we will leverage a dataset of over 1.5 million patients with T2DM in the Veterans Affairs (VA) system to identify multi-level predictors of prescription of cardio-renal preventive therapies. In Aim 2, we will conduct focus groups with patients and providers to qualitatively explore contextual determinants of the under-prescription of cardio-renal preventive therapies. In the independent phase of the award (Aim 3), we will leverage findings form Aims 1 and 2 to implement an educational intervention aimed at improving primary care providers’ knowledge and self-efficacy regarding cardio-renal preventive therapies in one medical facility. The components of the educational intervention are: 1) an educational toolkit consisting of an informational booklet, fact sheets/infographics, and informational posters for use in clinics; 2) primary care provider champions who will serve as reference providers regarding prescription of cardio-renal preventive therapies; and 3) interdisciplinary case-conferences regarding appropriate prescription of cardio-renal therapies. We will evaluate the change of primary care providers’ knowledge and self-efficacy before and after the intervention and compare changes in the rates of prescription of cardio-renal preventive therapies with a “passive” control medical facility. The completion of the proposed research and training in implementation science and mixed-methods research will be instrumental to establish Dr. Lamprea Montealegre’s independent research career at the intersection of CVD epidemiology and implementation science. In particular, the new set of skills in implementation science will allow Dr. Lamprea Montealegre to lead research and clinical programs on CVD prevention through the systematic detection and treatment of CKD, and to become a national leader in preventive cardio-renal care.