Lowering Blood Pressure Among Hypertensives with Screen-Detected Kidney Disease

描述(申请人提供)：糖尿病和高血压是与慢性肾脏疾病(CKD)和终末期肾脏疾病(ESRD)相关的最常见的疾病。与糖尿病不同的是，在美国，没有普遍推荐或实施在非糖尿病高血压成人中定期筛查CKD。绝大多数慢性肾脏病患者和他们的提供者并不知道这种疾病。因此，在患有高血压的非糖尿病成人中识别CKD患者是将循证方法转化为临床实践以减轻CKD负担的重要机会。我们先前的工作表明，与单独使用肌酐相比，使用肌酐、胱抑素C和尿白蛋白/肌酐比率来检测CKD的“三重标记物方法”大大增强了对并发症风险最高的人的识别。控制血压仍然是慢性肾脏病管理的主要内容；在临床实践中，由护士和药剂师领导的计划在改善血压控制方面是最有效的。因此，这项建议的目的是评估改善患有未识别CKD的非糖尿病高血压患者的血压控制的策略，我们提出了一项实用的整群随机临床试验，以改善在初级保健中筛查发现的CKD的非糖尿病高血压成年人的血压控制。第一个干预措施将评估护士主导的筛查和教育策略的有效性，该策略利用“三重标记”CKD筛查方法，再加上患者和提供者的教育，与常规护理相比。第二项干预将评估与筛查教育策略和常规护理相比，由护士和临床药剂师共同领导的筛查、教育和强化治疗计划是否可以改善CKD高危人群的血压管理。基于初级保健的慢性护理模式，该项目旨在利用现有的多学科团队来改善血压水平，并增加肾素-血管紧张素系统(ACE/ARB)抑制剂的适当使用。我们还将使用REACH、有效性、采用、实施和维护(RE-AIM)框架评估这些计划的可行性和流程实施。如果成功，这些干预措施可能有助于减轻慢性肾脏病及其相关并发症的负担。

DESCRIPTION (provided by applicant): Diabetes and hypertension are the most common conditions associated with chronic kidney disease (CKD) and end stage renal disease (ESRD). In contrast to diabetes, regular screening for CKD among non- diabetic hypertensive adults in the U.S. is not universally recommended or implemented. The vast majority of persons with CKD and their providers are unaware of the disease. Therefore, identification of persons with CKD among non-diabetic adults with hypertension represents an important opportunity to translate evidence- based approaches into clinical practice to reduce the burden of CKD. Our prior work has shown that a "triple- marker approach" to detect CKD using creatinine, cystatin C and the urinary albumin-to-creatinine ratio greatly enhanced identification of persons at highest risk for complications, compared with creatinine alone. Control of BP remains the mainstay of CKD management; and programs led by nurses and pharmacists have been the most effective at improving BP control in clinical practice. Therefore, the goal of this proposal is to evaluate to strategies to improve BP control among non-diabetic hypertensive persons with unrecognized CKD, We propose a pragmatic, cluster-randomized clinical trial to improve BP control for non-diabetic, hypertensive adults with screen-detected CKD in primary care. The first intervention will evaluate the efficacy of a nurse-led screen-and-educate strategy that utilizes a "triple-marker" CKD screening approach, coupled with both patient and provider education, compared with usual care. The second intervention will evaluate whether a screen, educate, and intensify treatment program co-led by both a nurse and a clinical pharmacist can improve BP management among persons with highest risk CKD, compared with the screen-and-educate strategy and with usual care. Based on the Chronic Care Model for primary care, this project is specifically designed to leverage an existing multi-disciplinary team to improve BP levels and increase appropriate use of inhibitors of the renin-angiotensin system (ACE/ARB). We will also evaluate the feasibility and process implementation of these programs using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. If successful, these interventions could help to reduce the burden of CKD and its associated complications.