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），导致相当大的发病率、死亡率和死亡率。 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-以及 系统层面的障碍导致了对这些患者的护理中存在的众所周知的差距，导致了不良结局。 考虑到CKD人群的不断增长，肾病学家的相对缺乏，以及高风险患者的零散护理， 因此，需要新的工具来提高CKD护理的质量和安全性以及临床结果。 人口健康管理（PHM）通过汇总和分析跨区域的数据来改善健康状况。 人口，以推动一致的，基于证据的护理。使用电子健康记录（EHR）的CKD PHM可以 一项可持续的战略，以克服医生和系统一级的障碍。基于EHR的PHM可以提高 识别高风险CKD患者;增加使用循证、广泛可用和成本低廉的 有效干预;加强用药安全。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登记研究包含实时数据和嵌入式指标，用于使用经验证的 风险预测模型，审查药物暴露和监测护理过程。我们有 成功地利用这一工具，试行了基于EHR的PHM干预措施，目标是及时发现 高风险CKD，实施远程肾病指导以改善循证CKD护理，以及 提供药物安全性审查和标准化CKD患者教育。 本提案的总体目标是测试多方面的EHR为基础的PHM的有效性 干预措施，以改善高危患者的循证CKD护理。大学 匹兹堡广泛的PCP网络提供了理想的环境，以评估330名PCP护理干预 超过48万名患者使用Epic EHR。我们将进行一项为期42个月的务实的随机分组研究， 在约1，700名PCP管理的高风险CKD患者中进行的对照试验，以确定基于EHR的 PHM改善了护理和临床结果的关键过程。我们假设基于EHR的PHM将 改善高血压控制，在高血压患者中使用肾素血管紧张素醛固酮系统抑制剂 避免肾脏禁忌药物（目的1）和延缓CKD进展（目的2）。 这种新的干预措施受益于基于PCP利益相关者反馈的定制， 医疗中心和健康计划的支持，以及PCP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 PCP负荷。CKD PHM可以提供一种可持续的，资源丰富的方法来改善CKD护理，结果， 和安全性此外，我们的实用集群RCT将为PHM仪表板生成代码， 在美国采用了门诊EHR，促进了CKD护理的传播和潜在转型。

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.