Can a CDS System Improve Hypertension Management With CKD?

Hypertension affects 60% to 90% of people with chronic kidney disease (CKD) and is a risk factor for adverse outcomes, such as kidney failure, cardiovascular events, and death. Therefore, lowering blood pressure (BP) is a key goal of published CKD treatment guidelines.

Primary care providers (PCPs) play an important role in identifying patients with CKD and addressing CKD risk factors, including hypertension. Unfortunately, research shows that PCPs are sometimes unaware of CKD management guidelines and have trouble implementing them. Computerized clinical decision support (CDS) systems are designed to assist by providing patient-specific information and evidence-based recommendations. However, CDS systems have demonstrated mixed results for CKD management.

CDS systems have shown decreased annualized loss of estimated glomerular filtration rate (eGFR), increased rates of diagnosis, increased urine albumin testing, and increased referral to nephrologists. However, they have not demonstrated a significant benefit for mitigating cardiovascular risk factors, including BP control. Incorporating principles of behavioral economics could help increase the effectiveness of CDS systems by addressing psychological factors that impact decision-making.

Lipika Samal, MD, MPH, and fellow researchers examined whether PCP use of an intervention, including a computerized CDS system based on behavioral economic principles and human-centered design, would result in a decrease in patients’ systolic BP (SBP) compared with usual care. Their findings were published in JAMA Internal Medicine. This study took place within the Brigham and Women’s Primary Care Practice-Based Research Network, and PCPs were the intervention’s target. Using a matched-pair randomized design, researchers randomized one PCP in each pair to the intervention group and the other to the usual care group. The CDS system provided tailored, evidence-based recommendations to PCPs, including initiation or titration of renin-angiotensin-aldosterone system inhibitors. Patients in the control group received usual care from PCPs, with the CDS system functioning in silent mode.

All patients aged ≥18 years who visited a PCP at any of the intervention practices during the 2 years preceding the first visit during the study intervention period were eligible for the study. After the study started, each patient who had an office visit with a PCP and met criteria for CKD stage 3 or 4 (two prior eGFR measures of 16 to 59 mL/min/1.73 m² within the previous 2 years separated by 90 days or two prior urine albumin-to-creatinine ratio measures greater than 30 mg/g within the previous 2 years separated by 90 days) and uncontrolled hypertension (at least one ambulatory SBP measure greater than 140 mmHg within the 2 years preceding the visit at which the patient was assessed for study inclusion, plus an elevated SBP measure at the baseline visit) were included in the study.

A total of 174 PCPs and 2026 patients (mean [SD] age, 75.3 [0.3] years; 1223 [60.4%] female; mean [SD] SBP at baseline, 154.0 [14.3] mmHg) were selected for the study. Of those, 87 PCPs and 1029 patients were randomized to the intervention; 87 PCPs and 997 patients were randomized to usual care. In total, 1714 (84.6%) patients were treated for hypertension at baseline. There were 1623 (80.1%) patients with an SBP measurement at 180 days.

The primary outcome was change in mean SBP from baseline to 180 days in the CDS versus usual care group. Primary analysis was a repeated measures linear mixed model using SBP at baseline, 90 days, and 180 days in an intention-to-treat repeated measures model to account for missing data. Secondary outcomes included BP control and patient outcomes, including the percentage of patients who received an action supported by the CDS recommendations.

A statistically significant difference in mean SBP change was observed in the intervention group versus the usual care group (change, −14.6 [95% CI, −13.1 to −16.0] mmHg vs −11.7 [95% CI, −10.2 to −13.1] mmHg; P=.005). There was no difference in the proportion of patients who achieved BP control in the intervention group versus the control group (50.4% [95% CI, 46.5%-54.3%] vs 47.1% [95% CI, 43.3%-51.0%]). More patients in the intervention group received an action aligned with the CDS recommendations than those in the usual care group (49.9% [95% CI, 45.1%-54.8%] vs 34.6% [95% CI, 29.8%-39.4%]; P<.001).

The authors acknowledged limitations of their study, including a small absolute effect size, unequal sex distribution and diastolic BP in study groups, possible falsely elevated BP measurements due to using first measurement, and possible imbalance among groups after four PCPs left their practices postrandomization. In addition, much of the decrease in SBP from baseline to 180 days could be related to regression to the mean. Finally, the effect in the intervention group could be attributed to the automated diagnosis of CKD and uncontrolled hypertension by the CDS system, rather than other features of the CDS.

In conclusion, the researchers wrote, “This randomized, clinical trial found that patients whose PCPs were randomized to a CDS intervention based on behavioral economics principles and human-centered design methods experienced a statistically significant decrease in SBP at 180 days compared with the decrease in SBP of patients whose PCPs were randomized to the usual care group. The CDS intervention group had a modest improvement in SBP, but no difference in the proportion achieving adequate control.” The results suggest a CDS system could lead to better management of uncontrolled hypertension.

Source: JAMA Internal Medicine