Grand Rounds June 23, 2023: Improving Delivery of Care for Chronic Kidney Disease, Diabetes and Hypertension (Miguel A. Vazquez, MD and George Oliver, MD, PhD)

Posted on by Hannah Webster

Speakers

Miguel A. Vazquez, MD
Robert Toto, MD
University of Texas Southwestern Medical Center
Dallas, TX

George Oliver, MD, PhD
Parkland Center for Clinical Innovation
Dallas, TX

Keywords

ICD-Pieces, pragmatic clinical trial, chronic kidney disease, type 2 diabetes, hypertension

Key Points

  • ICD-Pieces, an NIH Collaboratory Trial, was a cluster randomized, pragmatic clinical trial testing an intervention that used an electronic health record–based algorithm and practice facilitators in 141 primary care practices.
  • The study team randomly assigned more than 11,000 adults to receive either the intervention or usual care. The study population was diverse—20% were Black and almost 20% were Hispanic or Latino—representative of the population with chronic kidney disease, type 2 diabetes, and hypertension in the United States.
  • In the intervention group, the study team used an algorithm to identify patients in the electronic health record in real time.
  • Practice facilitators worked with the participating primary care providers and patients in the intervention group to meet blood pressure targets, promote use of appropriate medications, achieve goals for blood glucose control, and engage in other guideline-directed care. The intervention period lasted 12 months. The primary outcome was hospitalization for any reason.
  • The hospitalization rate was similar between the intervention group and the usual care group. Rates of key secondary outcomes, such as emergency department visits and cardiovascular events, were also similar between the groups.
  • The study team successfully completed study in 4 different health systems with a variety of EHR systems. The intervention was delivered with a high degree of fidelity, showing the feasibility of the study approach.
  • Engaging multiple stakeholders is key. Technology is helpful but not sufficient; delivery of the intervention required sustained effort.

Discussion Themes

- A more sustained intervention, greater engagement with pharmacists, and use of more patient-facing technology would have added to the success of intervention delivery.

- The longer the trial duration, the more complicated the challenges with site-level staff turnover, unanticipated changes in institutional policies and procedures, and changes in technology and EHR systems.

Tags

#pctGR, @Collaboratory1