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，并与过高的死亡率和发病率有关。更好的管理可以减缓疾病的进展，防止代谢并发症，并减少心血管后果。然而，患者和提供者对CKD的认识不足，对治疗策略的了解不足，以及无效的患者与提供者的沟通可能会阻碍这些努力。我们建议评估一套增量强化的干预措施，以提高认识、改善知识并促进更好的沟通，可能导致更好的临床结果。这些干预措施基于慢性护理模式和社会认知理论，将在10家社区卫生诊所寻求初级保健的高危、服务不足的人群中进行评估，使用嵌套在准实验研究设计中的前瞻性随机试验。在四个诊所，我们将引入一个包含决策支持的自动CKD登记处，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登记处)。在另外六个诊所，我们将引入增强的CKD登记处，其中将包括基本CKD登记处的所有组成部分，并加强以索赔为基础的护理监督和护理团队反馈。我们将这六家诊所的患者随机分配到1)增强型CKD注册表干预或2)增强型CKD注册表Plus，其中包括一项额外的患者级干预：提供CKD教育和自我管理支持的自动电话呼叫，并由与护理团队沟通的健康教练根据需要进行后续跟进。我们将比较我们的主要结果，血压的变化，实施基本CKD注册表前后；增强CKD注册表与基本CKD注册表中的患者之间；以及增强CKD注册表Plus与增强CKD注册表中的患者之间的结果。我们还将检查二级临床(例如，蛋白尿、糖化血红蛋白)、中间(例如，意识、激活、ACE/ARB的使用)和可持续性(例如，达到、采用、维持)结果。这项建议为CKD进展和并发症的高危患者联合了一个大型安全网卫生系统，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系统中推广，在类似的安全网系统中在更大的范围内推广，并在临床特征不那么复杂的患者群体中推广。因此，这项研究对改善美国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.