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. 2020 Nov;35(Suppl 2):849-869.
doi: 10.1007/s11606-020-06103-7. Epub 2020 Oct 26.

Improving Blood Pressure Management in Primary Care Patients with Chronic Kidney Disease: a Systematic Review of Interventions and Implementation Strategies

Celia C Kamath  1   2   3 , Claudia C Dobler  4 , Rozalina G McCoy  5   6   7 , Michelle A Lampman  5   6 , Atieh Pajouhi  7 , Patricia J Erwin  8 , John Matulis  7 , Muhamad Elrashidi  7 , Joseph Darcel  9 , Mouaz Alsawas  4 , Zhen Wang  4 , Nilay D Shah  5   6 , M Hassan Murad  4 , Bjorg Thorsteinsdottir  5   6   10
Affiliations

Improving Blood Pressure Management in Primary Care Patients with Chronic Kidney Disease: a Systematic Review of Interventions and Implementation Strategies

Celia C Kamath et al. J Gen Intern Med. 2020 Nov.

Abstract

Introduction: Chronic kidney disease (CKD) is widely prevalent, associated with morbidity and mortality, but may be lessened with timely implementation of evidence-based strategies including blood pressure (BP) control. Nonetheless, an evidence-practice gap persists. We synthesize the evidence for clinician-facing interventions to improve hypertension management in CKD patients in primary care.

Methods: Electronic databases and related publications were queried for relevant studies. We used a conceptual model to address heterogeneity of interventions. We conducted a quantitative synthesis of interventions on blood pressure (BP) outcomes and a narrative synthesis of other CKD relevant clinical outcomes. Planned subgroup analyses were performed by (1) study design (randomized controlled trials (RCTs) or nonrandomized studies (NRS)); (2) intervention type (guideline-concordant decision support, shared care, pharmacist-facing); and (3) use of behavioral/implementation theory.

Results: Of 2704 manuscripts screened, 73 underwent full-text review; 22 met inclusion criteria. BP target achievement was reported in 15 and systolic BP reduction in 6 studies. Among RCTs, all interventions had a significant effect on BP control, (pooled OR 1.21; 95% CI 1.07 to 1.38). Subgroup analysis by intervention type showed significant effects for guideline-concordant decision support (pooled OR 1.19; 95% CI 1.12 to 1.27) but not shared care (pooled OR 1.71; 95% CI 0.96 to 3.03) or pharmacist-facing interventions (pooled OR 1.04; 95% CI 0.82 to 1.34). Subgroup analysis finding was replicated with pooling of RCTs and NRS. The five contributing studies showed large and significant reduction in systolic BP (pooled WMD - 3.86; 95% CI - 7.2 to - 0.55). Use of a behavioral/implementation theory had no impact, while RCTs showed smaller effect sizes than NRS.

Discussion: Process-oriented implementation strategies used with guideline-concordant decision support was a promising implementation approach. Better reporting guidelines on implementation would enable more useful synthesis of the efficacy of CKD clinical interventions integrated into primary care.

Prospero registration number: CRD42018102441.

Keywords: blood pressure control; chronic kidney disease; guideline implementation; implementation strategies; primary care practitioner interventions; systematic review.

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Conflict of interest statement

The authors declare that they do not have a conflict of interest.

Figures

Figure 1
Figure 1
Conceptual model to address heterogeneity of interventions targeting CKD management.
Figure 2
Figure 2
PRISMA flow diagram of included studies.
Figure 3
Figure 3
Meta-analysis of CKD interventions on BP target achievement (only RCTs).
Figure 4
Figure 4
Meta-analysis of CKD interventions on BP target achievement (RCTs and NRS).
Figure 5
Figure 5
Meta-analysis of CKD interventions on reduction in systolic BP.
Figure 6
Figure 6
Impact of study design on BP target achievement (RCTs and NRS).
Figure 7
Figure 7
Distribution of concept mapped categories and implementation strategies across all included studies.
Figure 8
Figure 8
Impact of implementation framework on BP target achievement (RCTs and NRS).
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