Electronic Tools to Increase Recognition and Improve Primary Care Management for Hypertension in Chronic Kidney Disease: A Multi-site Randomized Clinical Trial

ABSTRACT Chronic kidney disease (CKD) affects 1 in 7 adults in the United States. Despite its high prevalence, approximately 90% of those with kidney disease are not aware they have it. In addition, hypertension (HTN) remains a leading cause of end stage renal disease and greatly impacts the risk for adverse cardiovascular outcomes in the CKD population. Primary care physicians (PCPs) are uniquely positioned to effectively manage CKD through early identification and use of evidence-based treatments, but they face time-constraints and competing demands. Clinical decision support (CDS) tools can bridge that gap by utilizing data within the electronic health record (EHR) to provide recommendations. In our prior work, we incorporated behavioral economic principles and human-centered design in a CDS tool to deliver tailored, actionable, and evidence-based recommendations for the management of HTN within a primary care CKD population. We demonstrated that the CDS had a statistically significant effect on lowering systolic blood pressure (SBP), in addition to increasing prescription for evidence-based renin-angiotensin-aldosterone system inhibitor (RAASi) therapy. In this project, we aim to establish the generalizability of these findings by implementing the CDS tool across three health systems. We will also update the CDS to address medication nonadherence and to incorporate new clinical practice recommendations for sodium glucose co-transporter-2 inhibitors (SGLT2i). The specific aims of this project are to 1) adapt and pilot test CKD CDS in multiple health systems, 2) determine the effectiveness of the CDS alerts on lowering SBP and increasing RAASi/SGLT2i prescriptions in a pragmatic randomized trial in 36 primary care clinics across three health systems and 3) use two implementation frameworks, TAM3 and Proctor’s Implementation Outcomes Framework, to assess implementation outcomes and factors influencing implementation in order to inform further dissemination. In summary, this renewal application seeks to establish the scalability of a CDS tool, based on behavioral nudge alerts, across diverse patient populations and various EHR workflows for the management of HTN in adults with CKD within primary care settings.