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

改善慢性肾脏疾病(CKD)患者生存时间和质量的最大机会 是及早识别和干预导致慢性肾脏病进展和病情恶化的慢性病 结果。尽管慢性肾脏病和高血压(HTN)都不是慢性肾脏病进展的主要危险因素 两者都很难诊断，通常都无法被儿科医生识别。由于慢性肾脏病患者一般都得到他们的护理 对于初级保健医生(PCP)来说，基于初级保健的干预措施具有最大的改善潜力 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，以改善 初级保健中的CKD管理。然而，电子病历、登记和临床决策支持的影响 (CDS)在CKD中一直很温和。假设：CKD人群的平均收缩压可以是 通过干预减少，具有三个创新特征：1)合成EHR数据的方法，以便 识别诊断不足的慢性疾病，2)通过人为因素反复改善CDS内容 方法以最大限度地提高CDS的“信息量”，以及3)使用行为经济学原理来 在CDS内部和外部创建行为“轻推”。具体目标1：开发和验证 干预。具体目标1a：开发和验证将：1)综合现有实验室的CDS 检查、用药指令和生命体征数据；2)提高对CKD的认识；3)提高对 CKD患者的HTN失控；以及4)提供循证的CKD和HTN管理 建议。验证将包括为期8周的静默磨合期和图表审查。特定目标 1B：使用人为因素方法提高CDS内容的“信息量”，特别是通过 进行一项“大声思考”的研究。具体目标1c：制定包括三个方面的“包围式”干预措施 行为“轻推”：1)预先检查默认订单，2)与PCP进行面对面会议，以获得他们的 承诺遵循CDS的建议，以及3)如果PCP这样做了，则需要一个必要的“负责任的理由” 没有遵循CDS的建议。具体目标二：检验干预效果。特定的 目标2a：评估目标1中开发的干预措施是否显著降低平均收缩压血 有血压的CKD患者人群中的血压&GT；140/90，N=2,350(N来自EHR数据 关于15家诊所的初级保健病人)。我们将务实地评估干预的有效性， 整群随机对照试验，在医生水平上随机进行(180个PCP)。次要结果 将包括针对高血压的具体流程措施，如强化治疗。具体目标2b： 评估干预是否改善了CKD护理质量的流程措施，包括：记录在案 慢性肾脏病的诊断、年度血肌酐检测和年度尿白蛋白检测。具体目标2c：执行 交叉研究，以评价干预对PCP行为和PCP意向的影响 改变行为，通过有效的12个项目的问卷来衡量。

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.