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 1 a: 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 1 b: To improve the ?informativeness? of the content of the CDS using human factors methods, specifically by conducting a ?think-aloud? study.
Specific Aim 1 c: 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 2 a: 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 2 b: 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 2 c: 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.
We now know that treating chronic kidney disease in its early stages can prevent dialysis and reduce heart problems that go along with kidney disease. Computerized tools may help primary care doctors to diagnose the disease earlier and computer reminders may help doctors to prescribe the best treatments for high blood pressure which will prevent dialysis and heart problems. In this project we will create computer reminders and we will test them in clinics to see if they improve treatment of high blood pressure in early chronic kidney disease.
