PopulAtioN health management to OPTImize Care in CKD (PANOPTIC-CKD)

数以百万计的成年人患有慢性肾脏疾病(CKD)，导致大量的发病率、死亡率和 医疗保健费用。这些影响集中在高危疾病患者身上。几个提供商-和 系统层面的障碍导致在对这些患者的护理方面出现众所周知的差距，从而导致糟糕的结果。 考虑到不断增长的慢性肾脏病人口，相对缺乏的肾脏病医生，以及分散的护理，高风险 患者接受治疗后，需要新的工具来改善CKD护理的质量和安全性以及临床结果。 人口健康管理(PHM)通过聚合和分析 以推动始终如一的循证护理。使用电子健康记录(EHR)的CKD PHM可以 一个可持续的战略，以克服医生和系统层面的障碍。基于EHR的PHM可以改善 识别高危慢性肾脏病患者；增加循证、广泛可用和成本- 有效的干预措施；并提高用药安全。我们已经开发了实施和 检查基于EHR的PHM干预的影响。我们的多学科团队构建了一个动态的 CKD注册表，包含实时数据和嵌入的指标，用于使用经验证的 风险预测模型，审查用药暴露，并监测护理过程。我们有 成功利用此工具试行了基于EHR的PHM干预，旨在及时检测 高风险慢性肾脏病，实施远程肾脏病指导，以改善循证慢性肾脏病护理，以及 提供药物安全审查和标准化的慢性肾脏病患者教育。 这项建议的主要目的是测试基于多方面EHR的PHM的有效性 改善高危患者提供循证慢性肾脏病护理的干预措施。伊利诺伊大学 匹兹堡广泛的PCP网络为评估干预提供了理想的环境，330名PCP照顾 在使用Epic EHR的同时，为超过48万名患者提供服务。我们将执行为期42个月的务实、随机分组 对1700名由PCP管理的高危CKD患者进行的对照试验，以确定基于EHR的 PHM改善了护理的关键过程和临床结果。我们假设基于EHR的PHM将 改善高血压控制，使用肾素-血管紧张素-醛固酮系统抑制剂治疗高血压 蛋白尿，避免肾脏禁忌症药物(目标1)和延缓CKD进展(目标2)。 这一新的干预措施得益于基于PCP利益相关者反馈的定制，执行级别 来自医疗中心和健康计划的支持，以及来自初级保健医生的热情支持。这项研究直接 响应国家初级保健组织的呼吁，使用EHR实施PHM，同时限制 五氯联苯负担。CKD PHM可以提供一种可持续的、足智多谋的方法来改善CKD的护理、结果 和安全。此外，我们的实用集群RCT将为最广泛的PHM仪表板生成代码 在美国采用了动态EHR，促进了CKD护理的传播和潜在的转变。

Millions of adults have chronic kidney disease (CKD), leading to substantial morbidity, mortality and health care costs. These effects are concentrated in patients with high-risk disease. Several provider- and system-level barriers lead to well-described gaps in care for these patients, contributing to poor outcomes. Given the growing CKD population, the relative dearth of nephrologists, and the fragmented care that high-risk patients receive, novel tools are needed to improve the quality and safety of CKD care and clinical outcomes. Population health management (PHM) improves health by aggregating and analyzing data across a population to drive consistent, evidence-based care. CKD PHM using electronic health records (EHRs) can be a sustainable strategy to overcome physician- and system-level barriers. EHR-based PHM could improve the identification of patients with high-risk CKD; increase the use of evidence-based, widely available, and cost- effective interventions; and enhance medication safety. We have developed the tools needed to implement and examine the impact of an EHR-based PHM intervention. Our multidisciplinary team has constructed a dynamic CKD registry containing real-time data and embedded metrics for identifying high-risk CKD using validated risk-prediction models, reviewing medication exposures, and monitoring processes of care. We have successfully leveraged this tool to pilot an EHR-based PHM intervention that targets the timely detection of high-risk CKD, the implementation of remote nephrology guidance to improve evidence-based CKD care, and the provision of medication safety reviews and standardized CKD patient education. The overarching aim of this proposal is to test the effectiveness of a multifaceted EHR-based PHM intervention to improve the delivery of evidence-based CKD care in high-risk patients. The University of Pittsburgh's extensive PCP network offers the ideal setting to evaluate the intervention with 330 PCPs caring for over 480,000 patients while using the Epic EHR. We will perform a 42-month pragmatic, cluster randomized controlled trial in ~1,700 patients with high-risk CKD managed by their PCPs to determine whether EHR-based PHM improves key processes of care and clinical outcomes. We hypothesize that EHR-based PHM will improve hypertension control, use of renin angiotensin aldosterone system inhibitors in patients with albuminuria, and avoidance of renally contraindicated medications (Aim 1) and delay CKD progression (Aim 2). This novel intervention benefits from customization based on PCP stakeholder feedback, executive level support from the medical center and health plan, and enthusiastic support from PCPs. This study directly responds to calls from national primary care organizations to use EHRs to implement PHM while limiting the PCP burden. CKD PHM may provide a sustainable, resourceful approach to improving CKD care, outcomes, and safety. In addition, our pragmatic cluster RCT will produce code for PHM dashboards in the most widely adopted ambulatory EHR in the US, facilitating dissemination and a potential transformation in CKD care.