The overall goal of this proposal is to evaluate two strategies designed to reduce barriers to guideline- concordant chronic kidney disease (CKD) care among persons with previously documented reduced eGFRcreat (creatinine-based estimated glomerular filtration rate) in primary care. We will test whether or not an automated CKD clinical decision support system (CDSS) can improve blood pressure (BP) levels, disease awareness, staging, processes of care, and knowledge among persons with documented reduced eGFRcreat in primary care. We propose a three-arm, pragmatic, cluster-randomized clinical trial. Participating primary care providers (PCP) will be randomized to usual care or one of two interventions. The first intervention will evaluate the efficacy of an automated CDSS that utilizes the electronic health record to facilitate triple marker test ordering (creatinine, cystatin C and albuminuria for disease staging), guideline implementation and BP management, compared with usual care, among patients with previous eGFRcreat <60 ml/min/1.73m2. The second intervention goes a step further, and it will evaluate whether a CDSS plus a pharmacist-led CKD management program (CDSS PLUS) can improve BP management and patient CKD and non-steroidal anti-inflammatory drug (NSAID) toxicity knowledge among persons with confirmed higher-risk CKD (eGFRcreat-cys <45 or eGFR45- 59 plus ACR ?30), compared with CDSS alone. The primary clinical outcome is BP level, with secondary outcomes related to processes of care and patient knowledge.
In Aim 1, we will evaluate whether an automated CKD CDSS achieves lower BP levels, higher rates of BP control and appropriate use of ACE/ARB compared with usual care, among persons with eGFRcreat < 60 ml/min/1.73m2 in primary care. We hypothesize that the CKD CDSS will result in improved BP levels, compared to usual care, and that within the CKD CDSS group, utilization of ACE/ARB among persons with albuminuria will increase during follow-up.
In Aim 2, we will evaluate the acceptability and feasibility of implementing a CDSS for improving disease awareness and staging by primary care providers, compared with usual care, among persons with eGFRcreat < 60 ml/min/1.73m2. We hypothesize that the CKD CDSS will result in increased physician CKD awareness, staging and appropriate testing for albuminuria, cystatin C and CKD complications (anemia, hyperphosphatemia, hyperparathyroidisim) in persons with reduced eGFRcreat, and this will require low expenditures and will be readily accepted by PCPs and patients.
In Aim 3, we will evaluate whether a CDSS PLUS pharmacist-led CKD management program can improve BP levels and patient disease knowledge in persons with higher-risk CKD, compared to CDSS alone. We hypothesize that the pharmacist-led CKD management strategy will result in lower BP levels and higher rates of appropriate use of ACE/ARB, compared to the CDSS alone and that the pharmacist-led BP management program will be acceptable to PCPs, and it will result in higher levels of patient CKD and NSAID-avoidance knowledge compared with CDSS alone.
Kidney disease poses a major public health problem in the United States. We aim to test the implementation of a decision support system to improve care of persons with kidney disease in primary care. Our goal is to reduce complications and improve the lives of persons with kidney disease.
