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

项目总结/摘要 2型糖尿病（T2 DM）和慢性肾病（CKD）患者的风险极高 心血管疾病（CVD）。然而，它们不是最佳处方的循证心肾 预防性治疗可以大大降低这种风险。这些疗法，包括血管紧张素- 转化酶抑制剂/血管紧张素受体阻滞剂（ACEI/ARB），胰高血糖素样肽-1受体 GLP 1激动剂和钠-葡萄糖协同转运蛋白2抑制剂（SGLT 2 i），显著降低CVD风险， CKD进展的风险。因此，他们的最佳处方可能导致CVD负担的显着减少， T2 DM和CKD患者。 在该奖项的指导阶段，拟议的研究将调查主要因素 说明T2 DM和CKD患者中心肾预防性治疗处方不足。 为此，我们将采用定量分析与定性分析相结合的混合方法进行研究 探索.具体而言，在目标1中，我们将利用超过150万T2 DM患者的数据集， 退伍军人事务部（VA）系统，以确定心肾预防处方的多水平预测因素 治疗在目标2中，我们将与患者和提供者进行焦点小组讨论， 心肾预防性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2的发现， 实施教育干预，以提高初级保健提供者的知识和自我效能 在一个医疗机构进行心肾预防治疗。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、概况介绍/信息图表， 在诊所使用的信息海报; 2）作为参考的初级保健提供者冠军 提供者关于心肾预防性治疗处方;和3）跨学科病例会议 关于心肾治疗的适当处方。我们将评估初级保健的变化 提供者的知识和自我效能在干预前后，并比较变化率， 通过“被动”控制医疗设施开具心肾预防性治疗处方。 完成执行科学和混合方法方面的拟议研究和培训 研究将有助于建立博士Lamprea Montealegre的独立研究生涯， CVD流行病学和实施科学的交叉。特别是， 实施科学将使Lamprea Montealegre博士能够领导CVD的研究和临床项目 通过系统检测和治疗CKD预防，并成为全国领先的 预防性心肾护理。

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.