Chronic disease IMPACT (chronic disease early detection and improved management in primary care project): An Australian stepped wedge cluster randomised trial

Abstract

Background: Interrelated chronic vascular diseases (chronic kidney disease (CKD), type 2 diabetes (T2D) and cardiovascular disease (CVD)) are common with high morbidity and mortality. This study aimed to assess if an electronic-technology-based quality improvement intervention in primary care could improve detection and management of people with and at risk of these diseases.

Methods: Stepped-wedge trial with practices randomised to commence intervention in one of five 16-week periods. Intervention included (1) electronic-technology tool extracting data from general practice electronic medical records and generating graphs and lists for audit; (2) education regarding chronic disease and the electronic-technology tool; (3) assistance with quality improvement audit plan development, benchmarking, monitoring and support. De-identified data analysis using R 3.5.1 conducted using Bayesian generalised linear mixed model with practice and time-specific random intercepts.

Results: At baseline, eight included practices had 37,946 active patients (attending practice ≥3 times within 2 years) aged ≥18 years. Intervention was associated with increased OR (95% CI) for: kidney health checks (estimated glomerular filtration rate, urine albumin:creatinine ratio (uACR) and blood pressure) in those at risk 1.34 (1.26-1.42); coded diagnosis of CKD 1.18 (1.09-1.27); T2D diagnostic testing (fasting glucose or HbA1c) in those at risk 1.15 (1.08-1.23); uACR in patients with T2D 1.78 (1.56-2.05). Documented eye checks within recommended frequency in patients with T2D decreased 0.85 (0.77-0.96). There were no significant changes in other assessed variables.

Conclusions: This electronic-technology-based intervention in primary care has potential to help translate guidelines into practice but requires further refining to achieve widespread improvements across the interrelated chronic vascular diseases.

Keywords: Electronic medical records; cardiovascular disease; chronic kidney disease; diabetes mellitus; general practice.

Figure 1.

Overview of stepped wedge trial (showing excluded practice).

Figure 2.

Participant flow diagram.

Figure 3.

Risk factor assessments recorded as per national recommendations.

Figure 4.

Risk factor presence and disease testing in those at risk. ^I Chronic kidney disease. ^II Type 2 diabetes. ^III Cardiovascular disease.

Figure 5.

Chronic disease presence. ^I Chronic kidney disease. ^II Familial hypercholesterolaemia. ^III Type 2 diabetes. ^IV Peripheral vascular disease. ^v Ischaemic stroke. ^VI Ischaemic heart disease. ^VII Heart failure. ^VIII Atrial fibrillation.

Figure 6.

Chronic disease management. ^I Chronic kidney disease. ^II Angiotensin-converting enzyme inhibitor or angiotensin receptor blocker. ^III Type 2 diabetes. ^IV Estimated glomerular filtration rate. ^V Urine albumin:creatinine ratio. ^VI Glycated haemoglobin. ^VII Peripheral vascular disease. ^VIII Ischaemic stroke. ^IX Ischaemic heart disease. ^X Heart failure. ^XI Atrial fibrillation.