Clinical Decision Support for Hypertension Management in Chronic Kidney Disease: A Randomized Clinical Trial

Abstract

Importance: Chronic kidney disease (CKD) affects 37 million adults in the United States, and for patients with CKD, hypertension is a key risk factor for adverse outcomes, such as kidney failure, cardiovascular events, and death.

Objective: To evaluate a computerized clinical decision support (CDS) system for the management of uncontrolled hypertension in patients with CKD.

Design, setting, and participants: This multiclinic, randomized clinical trial randomized primary care practitioners (PCPs) at a primary care network, including 15 hospital-based, ambulatory, and community health center-based clinics, through a stratified, matched-pair randomization approach February 2021 to February 2022. All adult patients with a visit to a PCP in the last 2 years were eligible and those with evidence of CKD and hypertension were included.

Intervention: The intervention consisted of a CDS system based on behavioral economic principles and human-centered design methods that delivered tailored, evidence-based recommendations, including initiation or titration of renin-angiotensin-aldosterone system inhibitors. The patients in the control group received usual care from PCPs with the CDS system operating in silent mode.

Main outcomes and measures: The primary outcome was the change in mean systolic blood pressure (SBP) between baseline and 180 days compared between groups. The 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 blood pressure (BP) control and outcomes such as percentage of patients who received an action that aligned with the CDS recommendations.

Results: The study included 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] mm Hg), with 87 PCPs and 1029 patients randomized to the intervention and 87 PCPs and 997 patients randomized to usual care. Overall, 1714 patients (84.6%) were treated for hypertension at baseline. There were 1623 patients (80.1%) with an SBP measurement at 180 days. From the linear mixed model, there was a statistically significant difference in mean SBP change in the intervention group compared with the usual care group (change, -14.6 [95% CI, -13.1 to -16.0] mm Hg vs -11.7 [-10.2 to -13.1] mm Hg; P = .005). There was no difference in the percentage of patients who achieved BP control in the intervention group compared with the control group (50.4% [95% CI, 46.5% to 54.3%] vs 47.1% [95% CI, 43.3% to 51.0%]). More patients received an action aligned with the CDS recommendations in the intervention group 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 < .001).

Conclusions and relevance: These findings suggest that implementing this computerized CDS system could lead to improved management of uncontrolled hypertension and potentially improved clinical outcomes at the population level for patients with CKD.

Trial registration: ClinicalTrials.gov Identifier: NCT03679247.

Figure 1.. Participant Recruitment and Randomization Flowchart

BWPC PBRN indicates Brigham and Women’s Primary Care Practice-Based Research Network; PCP, primary care practitioner. ^aThe number of PCPs randomized includes all individual physicians with their own panel of patients and 10 teams of a physician and an advanced practice clinician (ie, physician assistant or nurse practitioner) who share a panel.

Figure 2.. Example of Best Practice Advisory (BPA) for Computable Phenotype 2A

Screenshot of BPA with explanation of trigger criteria, relevant clinical information, recommended actions, and required accountable justification (ie, Acknowledge Reason). Boxes represent items that initiate an action if selected, eg, the Order box for “Lisinopril, 10 mg, tablet” is selected, the medication will be ordered for the patient. By default, the Order boxes are selected for “Lisinopril 10 MG Tablet,” and “Basic Metabolic Panel in 1 week.” ACE indicates angiotensin-converting enzyme inhibitor; BMP, basic metabolic panel; BP, blood pressure; BWH, Brigham and Women's Hospital; CKD, chronic kidney disease; eGFR, estimate glomerular filtration rate; K, potassium; Pt, patient; SBP, systolic blood pressure.