A Technology-Driven Intervention to Improve Identification and Management of Chronic Kidney Disease in Primary Care

项目摘要 慢性肾脏病(CKD)是一种常见且严重的慢性疾病，常导致终末期肾病 疾病和重大心血管事件。尽管循证的慢性肾脏病治疗可以减缓疾病的进展 为了避免并发症，目前只有不到10%的CKD患者在 及时的时尚。该项目的目标是开发、实施和评估技术驱动的 以团队为基础的干预措施，以改善3-4期CKD患者的护理质量和临床结果。这个 建议的干预使用复杂的基于Web的临床决策支持(CDS)系统，该系统 无缝集成到电子健康记录(EHR)中，以：(A)在初级保健中识别患有CKD的成年人 (B)建议个体化的循证治疗选择，以增加适当使用 肾脏保护性降压药物，改善血压控制，改善血糖 糖尿病患者的管理；以及(C)向患者和提供者建议在合作和 咨询肾病学家可能是明智的。我们通过随机的方式严格测试干预的影响 分配30个初级保健诊所，约120名初级保健医生和6100名成年人 CDS干预与常规护理的3-4阶段CKD证据，并评估干预对5个关键因素的影响 慢性肾脏病患者的循证护理要素：(I)慢性肾脏病患者对慢性肾脏病的认识和诊断 符合诊断标准；(Ii)足够的血压控制；(Iii)最适血管紧张素转换酶 抑制剂或血管紧张素受体阻滞剂的使用；适当的血糖控制；以及(V)肾内科会诊 在适当的时候。这种干预被称为CKD-CDS，提供特定于患者和特定于阶段的CKD 初级保健提供者(PCP)和患者各有高识字率和低识字率的治疗选择 初级保健相遇，促进共同决策。此CKD-CDS将使用 在以前的CDS研究中取得了非常高的患者使用率的以前成功的方法 (&gt；75%的目标患者遇到)患有糖尿病和高心血管风险。NIH的可扩展性- 已开发的、非商业化的干预策略得到了其当前使用的支持(没有CKD 识别或具体建议)在4个大型医疗小组中提供护理，这些小组在 中西部4个州的农村和城市地区，研究合同将使用扩展到60多个安全网 2018年将在另外14个州开设诊所。如果将CKD-CDS添加到该工具是有效的，则干预是 可立即扩展，并可(A)提高对大量CKD患者的护理质量，从而减缓 慢性肾脏病的进展和生活质量的提高，(B)最大限度地提高大量公共和私人的临床回报 目前正在对复杂的门诊电子病历系统进行投资，以及(C)提供健康信息学 快速一致地将不断发展的循证CKD临床指南转化为交付的原型 在初级保健环境中提供个性化和协调的CKD护理。

Project Summary Chronic kidney disease (CKD) is a common and serious chronic disease that often leads to end-stage renal disease and major cardiovascular events. Although evidence-based CKD care can slow disease progression and avert complications, less than 10% of CKD patients currently receive major elements of CKD care in a timely fashion. The objective of this project is to develop, implement, and evaluate a technology-driven and team-based intervention to improve quality of care and clinical outcomes for patients with stage 3-4 CKD. The proposed intervention uses a sophisticated Web-based clinical decision support (CDS) system that is seamlessly integrated within the electronic health record (EHR) to: (a) identify adults with CKD at primary care encounters; (b) suggest personalized evidence-based treatment options to increase the appropriate use of renoprotective antihypertensive medications, improve blood pressure control, and improve glycemic management in patients with diabetes; and (c) suggest to patients and providers when collaboration and consultation with nephrologists may be advisable. We rigorously test the impact of the intervention by randomly assigning 30 primary care clinics with approximately 120 primary care physicians and 6100 adults with evidence of stage 3-4 CKD to the CDS intervention versus usual care and assess intervention impact on 5 key evidence-based elements of care for patients with CKD: (i.) recognition and diagnosis of CKD in patients who meet diagnostic criteria; (ii.) adequate blood pressure control; (iii.) optimal angiotensin converting enzyme inhibitor or angiotensin receptor blocker use; (iv.) adequate glucose control; and (v.) nephrology consultation when appropriate. The intervention, referred to as CKD-CDS, provides patient-specific and stage-specific CKD treatment options in high- and low-literacy formats to the primary care provider (PCP) and patients at each primary care encounter to facilitate shared decision making. This CKD-CDS will be implemented using previously successful methods that in previous CDS studies have achieved very high use rates with patients (>75% of targeted patient encounters) for diabetes and high cardiovascular risk. Scalability of this NIH- developed, non-commercialized intervention strategy is supported by its current use (without the CKD identification or specific recommendations) in 4 large medical groups that provide care to 2,000,000 patients in rural and urban areas in 4 Midwestern states, with research contracts to extend use to more than 60 safety net clinics in an additional 14 states in 2018. If the addition of CKD-CDS to this tool is effective, the intervention is immediately scalable and could (a) improve quality of care for large numbers of CKD patients, thereby slowing progression of CKD and improving quality of life, (b) maximize the clinical return on massive public and private investments now being made in sophisticated outpatient EHR systems, and (c) provide a health informatics prototype that rapidly and consistently translates evolving evidence-based CKD clinical guidelines into delivery of personalized and coordinated CKD care within primary care settings.