Electronic Tools to Increase Recognition and Improve Primary Care Management for Hypertension in Chronic Kidney Disease

改善慢性肾脏病（CKD）患者寿命和生活质量的最佳机会 早期识别和干预导致CKD进展和不良反应的慢性疾病 结果。尽管CKD和高血压（HTN）（CKD进展的主要风险因素）两者均不 由于难以诊断，两者往往不被PCP识别。由于CKD患者通常接受他们的护理， 从初级保健医生（PCP），以初级保健为基础的干预措施有最大的潜力，以改善 CKD患者的健康。电子健康记录（EHR）提供了一种创新的交付方法， 初级保健中的CKD管理。然而，EHR、注册和临床决策支持的影响 (CDS)在CKD中表现温和。假设：CKD人群的平均收缩压可以是 通过具有三个创新特征的干预措施减少：1）合成EHR数据的方法， 识别诊断不足慢性疾病，2）通过人为因素迭代改善CDS内容 方法，以最大限度地提高CDS的“信息”，以及3）使用行为经济学原则， 在CDS内部和外部创建行为“助推”。具体目标1：开发和验证 干预具体目标1a：开发和验证CDS，将：1）综合现有实验室 检查、药物医嘱和生命体征数据; 2）增加对CKD的识别，3）增加对 CKD患者中不受控制的HTN;以及4）提供基于证据的CKD和HTN管理 建议.确认将包括8周的静默导入期和图表审查。具体目标 1b：使用人为因素方法提高CDS内容的“信息量”，具体而言， 进行“有声思维”研究。具体目标1c：制定一项“环绕式”干预措施， 行为“轻推”：1）预先检查默认订单，2）与PCP面对面会议，以获得他们的 承诺遵循CDS建议，以及3）如果PCP确实 不遵循CDS的建议。具体目标2：测试干预措施的有效性。具体 目标2a：评价目标1中开发的干预是否显著降低平均收缩压 血压> 140/90的CKD患者人群中的血压，N= 2，350（N来自EHR数据 15个诊所的初级保健患者）。我们将以一种务实的、 整群随机对照试验，在医生水平上进行随机化（180名PCP）。次要结局 将包括针对高血压的具体过程措施，如强化治疗。具体目标2b： 评估干预是否改善了CKD护理质量的过程措施，包括：记录 CKD诊断、每年血清肌酐检查和每年尿白蛋白检查。具体目标2c： 交叉研究，以评估干预对PCP行为和PCP意图的影响， 改变行为，通过一份经过验证的12项问卷进行测量。

The greatest opportunity to improve the length and quality of life for patients with chronic kidney disease (CKD) is to identify and intervene early on the chronic conditions that contribute to CKD progression and poor outcomes. Although both CKD and hypertension (HTN), the main risk factor for CKD progression, are not difficult to diagnose, both often go unrecognized by PCPs. Since patients with CKD generally receive their care from primary care physicians (PCPs), primary care-based interventions have the greatest potential to improve health for CKD patients. Electronic health records (EHRs) present an innovative delivery approach to improve CKD management in primary care. However, the impact of EHRs, registries and clinical decision support (CDS) has been modest in CKD. Hypothesis: The mean systolic blood pressure of the CKD population can be decreased by an intervention with three innovative features: 1) methods to synthesize EHR data in order to identify under-diagnosed chronic conditions, 2) iterative improvement in CDS content through human factors methods to maximize the “informativeness” of the CDS, and 3) the use of behavioral economic principles to create behavioral “nudges” internal and external to the CDS. Specific Aim 1: To develop and validate the intervention. Specific Aim 1a: To develop and validate the CDS that will: 1) synthesize existing laboratory tests, medication orders, and vital sign data; 2) increase recognition of CKD, 3) increase recognition of uncontrolled HTN in CKD patients; and 4) deliver evidence-based CKD and HTN management recommendations. The validation will consist of an 8-week silent run-in period and chart review. Specific Aim 1b: To improve the “informativeness” of the content of the CDS using human factors methods, specifically by conducting a “think-aloud” study. Specific Aim 1c: To develop a “wrap-around” intervention including three behavioral “nudges”: 1) pre-checked default orders, 2) an in-person conference with PCPs to obtain their commitment to follow the CDS recommendations, and 3) a required “accountable justification” if the PCP does not follow the CDS recommendations. Specific Aim 2: To test the effectiveness of the intervention. Specific Aim 2a: To evaluate whether the intervention developed in Aim 1 significantly decreases mean systolic blood pressure in a population of CKD patients with blood pressure > 140/90, N=2,350 (N derived from EHR data about primary care patients at 15 clinics). We will evaluate the effectiveness of the intervention in a pragmatic, cluster-randomized controlled trial, randomized at the level of the physician (180 PCPs). Secondary outcomes will include hypertension-specific process measures, such as treatment intensification. Specific Aim 2b: To evaluate whether the intervention improves process measures for quality of CKD care including: documented CKD diagnosis, annual serum creatinine test, and annual urine albumin test. Specific Aim 2c: To perform a cross-over study in order to evaluate the effect of the intervention on PCP behavior and PCPs' intention to change behavior, as measured by a validated 12-item questionnaire.