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Clinical Decision Support for Hypertension Management in CKD
Quick Takes
- Use of a clinical decision support system for the management of hypertension in patients with chronic kidney disease resulted in a greater decrease in systolic BP when compared to patients treated with usual care.
- The proportion of patients who achieved adequate BP control was similar whether the primary care practitioner used a clinical decision support system or usual care.
Study Questions:
Does a computerized clinical decision support (CDS) system based on behavioral economic principles and human-centered design lead to a decrease in systolic blood pressure (SBP) in patients with chronic kidney disease (CKD) and uncontrolled hypertension?
Methods:
This was a multicenter, controlled trial randomized at the clinician level using a matched-pair design. One primary care practitioner (PCP) in each pair was randomized to the intervention group and the other to the usual care group. All patients aged ≥18 years with CKD (stage 3 or 4) and uncontrolled hypertension (at least one SBP measure >140 mm Hg during the 2 years preceding enrollment and an elevated SBP at the baseline visit) and had a visit with a PCP at any of the intervention sites during the 2 years preceding the first visit during the study period were eligible for inclusion. The intervention consisted of a CDS system within the electronic health record composed of 5 Best Practice Advisories. Advisories were triggered within the system based on computable algorithms that were developed to guide treatment choices. Recommended medication and laboratory orders were preselected in order to encourage the PCP to follow the recommendation. Usual care PCPs only received a brief statement about CKD guidelines prior to study initiation. CDS alerts were not visible to usual care PCPs but did continue to file in the background for study evaluation purposes. The primary outcome was the change in mean SBP between baseline and 180 days. Secondary outcomes included the proportion of patients with controlled BP (<140/90 mm Hg) at 180 days and orders coinciding with recommendations from the CDS system.
Results:
There were 174 PCPs randomized who cared for 2,026 patients (mean [SD] age, 75.3 [0.3] years; 60.4% female; mean [SD] SBP at baseline, 154.0 [14.3] mm Hg). There were 87 matched pairs of PCPs with 1,029 patients in the intervention group and 997 patients receiving usual care; 1,714 patients (84.6%) were being treated for hypertension at baseline. Clinical characteristics including SBP, weight, and documented comorbidities were similar between groups at baseline. The median number of antihypertensive medications prescribed was 2.0 in both study groups.
There were 1,623 patients (80.1%) with an SBP measurement at 180 days. Mean change in SBP was greater in the intervention group compared to usual care, -14.6 (95% confidence interval [CI], -13.1 to -16.0) mm Hg vs. -11.7 (95% CI, -10.2 to -13.1) mm Hg, p = 0.005. There was no significant difference in the proportion of patients who achieved BP control at 180 days, 50.4% (95% CI, 46.5% to 54.3%) of patients in the intervention group compared to 47.1% (95% CI, 43.3% to 51.0%) of patients in the usual care group. There were more patients in the intervention group who received an action that aligned with the CDS recommendations than in the usual care group (49.9% [95% CI, 45.1% to 54.8%] vs. 34.6% [95% CI, 29.8% to 39.4%]; p < 0.001).
Conclusions:
Patients with CKD and uncontrolled hypertension treated using a CDS system experienced a statistically significant decrease in SBP at 180 days compared with the decrease in SBP of patients who received usual care. However, the proportion of patients achieving adequate SBP control was not different between groups.
Perspective:
PCPs are crucial in reducing the burden of CKD by recognizing and addressing risk factors, such as hypertension and diabetes. However, studies have shown PCPs often lack awareness of CKD treatment guidelines and encounter barriers to implementing those recommendations. While the purpose of CDS algorithms is to guide treatment based on patient-specific information and evidence-based guidelines, studies of these interventions have produced mixed results. Prior studies evaluating CDS systems have found positive outcomes in decreasing annualized loss of estimated glomerular filtration rates and increased rates of CKD diagnosis and referral to nephrologists. However, studies evaluating the effect on cardiovascular risk factors, including BP control, have shown no benefit. The current study was the first to demonstrate a reduction in the SBP at 180 days with use of a CDS system; however, the overall rate of BP control was not different than with usual care.
Clinical Topics: Prevention, Hypertension, Cardiovascular Care Team
Keywords: Hypertension, Renal Insufficiency, Chronic
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