Improving CKD Detection and Care in a High Risk Underserved Population

描述(由申请人提供)：越来越多的慢性肾脏疾病(CKD)患者是一个公共卫生挑战。一些干预措施已被证明在改善CKD患者的预后方面是有效的，但许多患者没有接受这些治疗。关于如何治疗慢性肾脏病的知识的进步与最佳护理的实施之间的差距对于某些少数族裔和少数族裔成员以及未得到充分服务的人群来说尤其大。这项建议的主要目标是改善对所有慢性肾脏病患者的护理，并制定可能被证明在服务不足的高危人群中特别有效的策略。我们的主要教学医院，Parkland Health and Hospital Systems(PHHS)，为达拉斯县的弱势群体提供服务，服务的主要是非裔美国人和西班牙裔美国人。PHHS有一个初级保健诊所网络，分布在整个社区，并被指定为医疗院。PHHS有一个全面运作的IT项目，即Parkland智能电子协调和评估系统(PICES)，该系统有助于利用电子病历在我们的患者群体中实施、协调和监控循证干预。这一建议的主要假设是，一种新的初级保健-肾脏内科联合护理模式将改善慢性肾脏病患者CKD和心血管并发症进展的危险因素的临床管理。我们还建议，一个新的健康信息技术平台的应用将使非裔美国人和西班牙裔患者群体能够更早地发现CKD，并促进CKD的护理和肾脏替代治疗的准备。第一个具体目标是改进在卫生和公众服务部服务的高危人群(主要是少数族裔)中发现慢性肾脏病的情况。第二个具体目标是实施经证明可以减缓慢性肾脏病进展和治疗相关疾病的干预措施。第三个具体目标是使患者为肾脏替代治疗的最佳启动做好准备，包括移植准备，如果需要透析，及时选择方式，放置通道，避免临时中心静脉导管。这种合作的初级保健/肾病护理模式的成功应用结合了新的健康信息技术，不仅有可能改善我们机构对少数族裔患者的护理，而且有可能改善美国所有CKD患者的护理。 公共卫生相关性：慢性肾脏疾病(CKD)是一种常见的医学问题，会导致更高的死亡率、住院率和成本。许多患者没有接受被证明有助于减缓肾脏疾病及其并发症进展的治疗。这项研究旨在改善对慢性肾脏病患者的护理，特别是那些处于最高风险的少数民族人群。

DESCRIPTION (provided by applicant): The growing number of patients with chronic kidney disease (CKD) is a public health challenge. Several interventions have been proven to be effective in improving outcomes for patients with CKD, but many patients do not receive these therapies. The gap between advances in knowledge of how to treat CKD and implementation of optimal care is especially large for members of certain ethnic and racial minorities and underserved populations. The main goal of this proposal is to improve the care of all patients with CKD and to develop strategies that may prove to be particularly effective in high risk underserved populations. Our main teaching hospital, Parkland Health and Hospital Systems (PHHS), cares for the underserved in Dallas County and serves a predominantly African-American and Hispanic population. PHHS has a network of primary care clinics distributed throughout the community and designated as Medical Homes. PHHS has a fully operational IT-enabled program, the Parkland Intelligent e- Coordination and Evaluation System (PIECES), that facilitates harnessing the electronic medical record to implement, coordinate and monitor evidence-based interventions in our patient population. The main hypothesis of this proposal is that a new model of joint primary care-nephrology care will improve clinical management of risk factors for progression of CKD and CV complications in patients with chronic kidney disease. We also propose that the application of a novel health information technology platform will allow earlier detection of CKD in African-American and Hispanic patient populations and facilitate CKD care and preparation for renal replacement therapy. The first specific aim is to improve detection of CKD in the high risk predominantly minority population served at PHHS. The second specific aim is to implement interventions proven to slow the progression of CKD and treat associated conditions. The third specific aim is to prepare patients for optimal initiation o renal replacement therapy including preparation for transplantation and if dialysis is needed, timely modality selection, access placement and avoiding temporary central venous catheters. Successful application of this collaborative primary care/nephrology model of care which incorporates new health information technology has the potential to improve the care not only for minority patients in our institution for all CKD patients in the United States. PUBLIC HEALTH RELEVANCE: Chronic kidney disease (CKD) is a common medical problem that leads to higher mortality, hospitalizations, and costs. Many patients do not receive treatments proven to help slow the progression of kidney disease and its complications. This study is directed to improving the care of CKD patients especially for those in minority populations that are at the highest risk.