Optimizing Renin Angiotensin System Blocker Use among Veterans with Kidney Disease

优化肾素血管紧张素系统阻滞剂在患有肾脏疾病的退伍军人中的使用

• 批准号: 10229343
• 负责人: Sankar Dass Navaneethan
• 金额: --
• 依托单位: MICHAEL E DEBAKEY VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2020
• 资助国家: 美国
• 起止时间: 2020-10-01 至 2025-09-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10229343
• 关键词: Address; Adverse event; Albuminuria; Algorithms; Ambulatory Care Facilities; Angioneurotic Edema; Angiotensin II Receptor; Angiotensin-Converting Enzyme Inhibitors; Antihypertensive Agents; Cardiovascular Diseases; Cardiovascular system; Caring; Cessation of life; Chronic Disease; Chronic Kidney Failure; Clinical; Cognitive; Communities; Cost Analysis; Cost Savings; Coughing; Creatinine; Data Set; Department of Defense; Diabetes Mellitus; Dialysis procedure; Diet Modification; Disease Progression; Diuretics; Dose; End stage renal failure; Event; General Population; Guidelines; Health Services Research; Health care facility; Healthcare Systems; High Prevalence; Human; Hypertension; Hypotension; Informatics; Information Retrieval; Intervention; Interview; Kidney Diseases; Learning; Life; Manuals; Medical center; Methodology; Morbidity - disease rate; Myocardial Ischemia; Natural Language Processing; New Agents; Outcome; Patients; Pharmaceutical Preparations; Physiological; Pilot Projects; Population; Potassium; Prevalence; Provider; Qualitative Research; Quality of life; Renin-Angiotensin System; Renin-Angiotensin-Aldosterone System; Reporting; Research Methodology; Research Priority; Risk; Savings; Secondary to; Sensitivity and Specificity; Serum; Site; Structure; System; Techniques; Testing; Text; Time; Training; Treatment Side Effects; United States; United States Department of Veterans Affairs; Variant; Veterans; Veterans Health Administration; base; care costs; care providers; communication aid; cost; cost effectiveness; design; diabetic; follow-up; high risk; high risk population; hyperkalemia; improved; inhibitor; innovation; mortality; mortality risk; non-diabetic; novel; pilot test; pilot trial; point of care; primary outcome; provider behavior; side effect; sound; standard of care; structured data; tertiary care; treatment as usual; unstructured data

Background: Prevalence of moderate to severe chronic kidney disease (CKD) is 70% higher in veterans than the general population. Annual cost for non-dialysis dependent CKD population care increased to $18 billion in FY 2016 for Veterans Administration. Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARBs) are considered standard of care for CKD patients as they improve cardiovascular outcomes and retard progression to end stage kidney disease. Among veterans with diabetes and CKD, only 66% are on ACEI or ARB with significant variation across facilities. Among the ~34% not receiving ACEI or ARB, it is unclear whether they were started on these agents, started but stopped due to an adverse event or never started on ACEI or ARBs for e.g. due to clinical inertia. ACEI/ARB discontinuation is associated with an increased need for dialysis and a higher risk of mortality. In this proposal, we plan to understand the proportion of underuse of ACEI/ARB attributed to side effects versus clinical inertia using structured datasets and unstructured provider text notes, and barriers to initiation and re-initiation (after being discontinued) of ACEI/ARB. Based on these learnings, we propose to pilot test a communication aid in patient aligned care teams (PACTs), which will assist clinicians to initiate or reinitiate ACEI/ARB therapy in CKD patients. Significance: Successful implementation of the proposed study will help us (a) understand the reasons for lack of initiation of ACEI or ARB and their discontinuation (b) successfully develop, refine and pilot test a communication aid to optimize ACEI/ARB use among CKD population. These could reduce kidney disease progression, an improvement in cardiovascular outcomes and potential cost savings for the VA system. Innovation: The project utilizes both structured and unstructured data using natural language processing (NLP) to understand the full context for underutilization of ACEI or ARBS. Furthermore, we utilize innovative qualitative techniques and human factors bests practices to study and address this important gap in care. Aim 1: To examine reasons for lack of initiation and discontinuation of ACEI or ARBs among CKD patients based on structured data and automated information extraction using NLP. Aim 2: To conduct semi-structured interviews with PACT providers and patients at two tertiary care facilities and their community-based outpatient clinics (CBOCs) to further understand the reasons for lack of initiation or discontinuation of ACEI or ARBs among veterans with CKD. Based on these interviews, we will refine a succinct communication aid targeted towards PACT providers which will allow them to effectively initiate and/or reinitiate ACEI/ARB in CKD patients (including those with prior side effects). Aim3: To pilot test a communication aid for clinicians to improve initiation of ACEI or ARB or re-initiation of ACEI or ARB after being discontinued due to an adverse event. Methodology: For Aim 1, we will identify CKD patients using VA structured datasets and will randomly partition them into training and a test set. We will then train our NLP system to achieve a target sensitivity and specificity of >90% compared with manual chart review to assess reasons for lack of initiation/reinitiation of ACEI/ARB. For Aim 2, we will conduct semi-structured patient and provider interviews to understand barriers towards lack of initiation or reinitiation of ACEI or ARBs in CKD patients. We will then refine the content of a communication aid (using a human factors expert) for use during the pilot trial in Aim 3. For Aim 3, we will conduct a pilot trial. All PACT providers at the intervention sites will receive the communication aid to improve initiation of ACEI/ARB or reinitiation of ACEI/ARB after being discontinued due to an adverse event. At the usual care sites, PACT providers will only receive a quarterly report of the proportion of their CKD patients not on an ACEI/ARB. Our primary outcome is the change in the proportion of CKD patients receiving ACEI/ARBs. Next Steps: If our pilot study in Aim 3 is successful, then we will aim towards a system-wide implementation of our communication aid throughout our VISN to improve ACEI or ARB use in veterans with CKD.

背景：退伍军人中中度至重度慢性肾脏病 (CKD) 的患病率比退伍军人高 70% 普通民众。非透析依赖型 CKD 人群的年度护理费用增加至 180 亿美元 退伍军人管理局 2016 财年。血管紧张素转换酶抑制剂 (ACEI) 和血管紧张素 II 受体阻滞剂 (ARB) 被认为是 CKD 患者的标准治疗方法，因为它们可以改善心血管疾病 结果并延缓进展为终末期肾病。在患有糖尿病和慢性肾病的退伍军人中，只有 66% 的患者接受 ACEI 或 ARB 治疗，但不同机构之间存在显着差异。其中 ~34% 未接受 ACEI 或 ARB，目前尚不清楚他们是否开始使用这些药物，开始但由于不良事件或停止 从未开始使用 ACEI 或 ARB，例如由于临床惰性。 ACEI/ARB 停用与 透析需求增加和死亡风险更高。在这个提案中，我们计划了解比例 使用结构化数据集和临床惰性来归因于副作用和临床惰性而导致的 ACEI/ARB 使用不足的情况 非结构化的提供者文本说明，以及启动和重新启动（停止后）的障碍 ACEI/ARB。基于这些经验，我们建议在患者护理中试点测试沟通辅助工具 团队 (PACT)，将协助临床医生对 CKD 患者启动或重新启动 ACEI/ARB 治疗。 意义：成功实施拟议的研究将有助于我们 (a) 了解以下原因： 缺乏 ACEI 或 ARB 的启动以及它们的终止 (b) 成功开发、完善和试点测试 沟通辅助以优化 CKD 人群中 ACEI/ARB 的使用。这些可以减少肾脏疾病 进展、心血管结局的改善以及 VA 系统潜在的成本节省。 创新：该项目通过自然语言处理利用结构化和非结构化数据 (NLP) 了解 ACEI 或 ARBS 未充分利用的完整背景。此外，我们利用创新 定性技术和人为因素最佳实践来研究和解决护理方面的这一重要差距。 目标 1：调查 CKD 患者未开始和停止 ACEI 或 ARB 的原因 基于结构化数据和使用 NLP 的自动信息提取。目标2：进行半结构化 对两个三级护理机构及其社区门诊患者的 PACT 提供者和患者进行访谈 诊所 (CBOC) 进一步了解未开始或停止 ACEI 或 ARB 的原因 患有 CKD 的退伍军人中。根据这些访谈，我们将针对以下目标完善简洁的沟通帮助 面向 PACT 提供者，这将使他们能够在 CKD 患者中有效启动和/或重新启动 ACEI/ARB （包括先前有副作用的药物）。目标 3：试点测试一种沟通辅助工具，以帮助临床医生改进 开始使用 ACEI 或 ARB，或因不良事件而停药后重新开始使用 ACEI 或 ARB。 方法：对于目标 1，我们将使用 VA 结构化数据集识别 CKD 患者，并随机 将它们划分为训练集和测试集。然后我们将训练我们的 NLP 系统以达到目标灵敏度和 与手动图表审查相比，特异性 >90%，以评估缺乏启动/重新启动的原因 ACEI/ARB。对于目标 2，我们将进行半结构化患者和提供者访谈，以了解障碍 CKD 患者缺乏开始或重新开始 ACEI 或 ARB 的情况。然后我们将完善a的内容 在目标 3 的试点试验期间使用沟通辅助工具（使用人为因素专家）。对于目标 3，我们将 进行试点。干预地点的所有 PACT 提供者都将获得沟通援助，以改善 开始 ACEI/ARB 或因不良事件而停药后重新开始 ACEI/ARB。在 常规护理网站中，PACT 提供者只会收到关于其 CKD 患者未接受治疗的比例的季度报告 在 ACEI/ARB 上。我们的主要结果是接受 ACEI/ARB 治疗的 CKD 患者比例的变化。 后续步骤：如果我们在目标 3 中的试点研究取得成功，那么我们将致力于在全系统范围内实施 我们在整个 VISN 中提供沟通帮助，以改善患有 CKD 的退伍军人的 ACEI 或 ARB 使用。