Kidney Coordinated Health Management Partnership
Condition: Chronic Kidney Diseases
MeSH terms: Kidney Diseases; Renal Insufficiency, Chronic
Study type: Interventional

Summary: 
      As part of a 42-month pragmatic, cluster randomized trial in 1,650 primary care patients with
      high-risk Chronic Kidney Disease (CKD), the investigators will test the effectiveness of a
      multifaceted Electronic Health Record (EHR)-based Population Health Management (PHM)
      intervention that targets improvements in the delivery of evidence-based CKD care.
    

Detailed description: 
      To test the effectiveness of a multifaceted Electronic Health Record (EHR)-based Population
      Health Management (PHM) intervention to improve the delivery of evidence-based Chronic Kidney
      Disease (CKD) care in patients with high-risk CKD. Investigators will perform a 42-month
      pragmatic, cluster randomized (at the practice level) controlled trial in 1,650 patients with
      high-risk CKD (as defined by validated risk prediction models or by current estimated
      Glomerular Filtration Rate (eGFR) value or recent decline in eGFR values) managed by their
      Primary Care Physicians (PCPs) to determine whether EHR-based PHM improves key processes of
      care and clinical outcomes.

      The investigators hypothesize that EHR-based PHM will improve hypertension control, use of
      renin angiotensin aldosterone system inhibitors (RAASi), and avoidance of renally
      contraindicated medications (Aim 1a-1c) and delay CKD progression (Aim 2).

      Investigators will also characterize the acceptability and experience of Primary Care
      Physicians (PCPs) in the intervention arm of the CKD PHM study (Aim 3).
    

Intervention name(s): EHR-based PHM; Usual Care
Intervention type(s): Other; Other
Intervention description(s): An EHR in-basket message will be sent to the patient's PCP which identifies the patient's high-risk CKD status and indicates that the patient will receive:
Nephrologist led electronic consultation: review of the patient's EHR with recommendations sent to the PCP every ~6 months,
Medication therapy management: PharmD led telephonic medication therapy management with the patient every ~6 months,
and Nurse led CKD patient education, every ~6-12 months
unless the PCP opts the patient out of the interventions (by responding to the EHR in-basket message and providing an opt-out reason or requesting an office consultation with nephrology).; Patients in the usual care arm will continue to receive CKD care guided by their PCPs as per usual care practices (i.e., specialty consultation, pharmacotherapy, nurse education, etc. may be ordered by the PCP according to their usual practice).
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Cluster randomized controlled trial with randomization occurring at the Primary Care Physician practice level
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: electronic health record; population health management; patient education; medication therapy management; electronic consultation; randomized controlled trial; pragmatic trial