Health IT Enhanced for CKD in Safety-Net Primary Care

描述（由申请人提供）：慢性肾脏疾病（CKD）在美国成年人中很常见，并且与过高的死亡率和发病率相关。更好的管理可以减缓疾病的进展，预防代谢并发症，减少心血管疾病的结局。然而，患者和提供者对CKD的认知度低，治疗策略知识不足，以及无效的患者-提供者沟通会阻碍这些努力。我们建议评估一套逐步强化的干预措施，以提高认识，改善知识，促进更好的沟通，可能导致更好的临床结果。基于慢性护理模型和社会认知理论的干预措施，将在10个社区卫生诊所寻求初级保健的高风险，服务不足的人群中进行评估，采用准实验研究设计的前瞻性随机试验。在四家诊所，我们将引入一个包含决策支持的自动化CKD注册系统，它将识别CKD患者，向提供者发送通知，并向患者和提供者提供教育材料（基本CKD注册）。在另外六家诊所，我们将引入增强CKD注册，其中将包括基本CKD注册的所有组成部分，并增加基于索赔的护理监测和护理团队反馈。我们将这6家诊所的患者随机分配到1)增强CKD登记干预组或2)增强CKD登记加组，其中包括一个额外的患者层面干预：提供CKD教育和自我管理支持的自动电话，以及由健康教练与护理团队沟通的基于需求的随访。我们将比较基本CKD注册表实施前和实施后的主要结局，血压变化；增强与基本CKD注册的患者之间的差异；以及强化CKD注册组与强化CKD注册组之间的差异。我们还将检查继发性临床（例如，蛋白尿，HbA1c），中间（例如，意识，激活，ACE/ARB使用）和可持续性（例如，覆盖，采用，维持）结果。该建议将CKD进展和并发症高风险患者的大型安全网卫生系统联合起来，以解决改善CKD管理的障碍。成功的干预措施可以在我们更大的医疗保健系统中推广，在类似的安全网系统中推广到更大的范围，并在临床情况不那么复杂的患者群体中推广。因此，本研究对改善美国CKD患者的健康状况具有重要意义。

DESCRIPTION (provided by applicant): Chronic kidney disease (CKD) is common in U.S. adults and is associated with excess mortality and morbidity. Better management could slow progression of disease, prevent metabolic complications, and reduce cardiovascular outcomes. However, low patient and provider awareness of CKD, inadequate knowledge of treatment strategies, and ineffective patient-provider communication can impede such efforts. We propose to evaluate an incrementally intensive set of interventions to enhance awareness, improve knowledge, and foster better communication, possibly leading to better clinical outcomes. The interventions, based on the Chronic Care Model and Social Cognitive Theory, will be evaluated in a high-risk, underserved population seeking primary care at 10 community health clinics, using a prospective randomized trial nested in a quasi- experimental study design. In four clinics, we will introduce an automated CKD registry incorporating decision support, which will identify patients with CKD, send notifications to providers, and provide educational materials to patients and providers (Basic CKD Registry). In six additional clinics, we will introduce the Enhanced CKD Registry, which will include all the components of the Basic CKD Registry, augmented with claims-based surveillance of care and care team feedback. We will randomize patients in these six clinics to either 1) the Enhanced CKD Registry intervention or 2) the Enhanced CKD Registry Plus, which includes an additional patient-level intervention: automated telephone calls offering CKD education and self-management support, with need-based follow-up by a health coach who communicates with the care team. We will compare our primary outcome, change in blood pressure, pre- vs. post-implementation of the Basic CKD Registry; between patients in the Enhanced vs. Basic CKD Registry; and between patients in the Enhanced CKD Registry Plus vs. the Enhanced CKD Registry. We will also examine secondary clinical (e.g., albuminuria, HbA1c), intermediate (e.g., awareness, activation, ACE/ARB use), and sustainability (e.g., reach, adoption, maintenance) outcomes. This proposal unites a large safety-net health system for patients at high risk for CKD progression and complications to address barriers to improved CKD management. Successful interventions can be extended throughout our larger healthcare system, on a wider scale in similar safety-net systems, and in patient populations with less complex clinical profiles. Thus, this study has important implications for improving the health status of CKD patients in the United States. PUBLIC HEALTH RELEVANCE: Chronic kidney disease, which is associated with significant morbidity and mortality, is highly prevalent in the United States, particularly among underserved populations. Improving disease awareness and health communication and maintaining active surveillance through tailored, proactive health IT can improve health outcomes among patients with CKD via activation of patients and providers and engagement in risk-reduction behaviors.