Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, PA 15261, USA.
Am J Kidney Dis. 2011 Dec;58(6):894-902. doi: 10.1053/j.ajkd.2011.08.028. Epub 2011 Oct 7.
Primary care physicians (PCPs) care for most non-dialysis-dependent patients with chronic kidney disease (CKD). Studies suggest that PCPs may deliver suboptimal CKD care. One means to improve PCP treatment of CKD is clinical decision support systems (CDSSs).
Cluster-randomized controlled trial.
SETTING & PARTICIPANTS: 30 PCPs in a university-based outpatient general internal medicine practice and their 248 patients with moderate to advanced CKD who had not been referred to a nephrologist.
2 CKD educational sessions were held for PCPs in both arms. The 15 intervention-arm PCPs also received real-time automated electronic medical record alerts for patients with estimated glomerular filtration rates <45 mL/min/1.73 m(2) recommending renal referral and urine albumin quantification if not done within the prior year.
Primary outcome was referral to a nephrologist; secondary outcomes were albuminuria/proteinuria assessment, CKD documentation, optimal blood pressure (ie, <130/80 mm Hg), and use of renoprotective medications.
The intervention and control arms did not differ in renal referrals (9.7% vs 16.5%, respectively; between-group difference, -6.8%; 95% CI, -15.5% to 1.8%; P = 0.1) or proteinuria assessments (39.3% vs 30.1%, respectively; between-group difference, 9.2%; 95% CI, -2.7% to 21.1%; P = 0.1). For intervention and control patients without a baseline proteinuria assessment, 27.7% versus 16.3%, respectively, had one at follow-up (P = 0.06). After controlling for clustering, these findings were largely unchanged and no significant differences were apparent between groups.
Small single-center university-based practice, use of a passive CDSS that required PCPs to trigger the electronic order set.
PCPs were willing to partake in a randomized trial of a CDSS to improve outpatient CKD care. Although CDSSs may have potential, larger studies are needed to further explore how best to deploy them to enhance CKD care.
初级保健医生（PCP）负责大多数非透析依赖的慢性肾脏病（CKD）患者的治疗。研究表明，PCP 可能无法提供最佳的 CKD 治疗。改善 PCP 治疗 CKD 的一种方法是临床决策支持系统（CDSS）。
整群随机对照试验。
在一所大学门诊普通内科实践中，30 名 PCP 及其 248 名中重度 CKD 患者未转介给肾病医生。
在两个臂中，对 PCP 进行了 2 次 CKD 教育课程。15 名干预组 PCP 还收到了实时自动化电子病历警报，提示估计肾小球滤过率<45 mL/min/1.73 m²的患者需要进行肾脏转诊和尿白蛋白定量检测，如果在过去 1 年内未进行，则建议进行检测。
干预组和对照组在肾脏转诊方面没有差异（分别为 9.7%和 16.5%；组间差异，-6.8%；95%CI，-15.5%至 1.8%；P=0.1）或蛋白尿评估（分别为 39.3%和 30.1%；组间差异，9.2%；95%CI，-2.7%至 21.1%；P=0.1）。对于没有基线蛋白尿评估的干预组和对照组患者，分别有 27.7%和 16.3%在随访时进行了评估（P=0.06）。在控制聚类后，这些发现基本保持不变，两组之间没有明显差异。
小的单中心大学实践，使用需要 PCP 触发电子医嘱集的被动 CDSS。
PCP 愿意参与一项随机试验，以改善门诊 CKD 治疗。尽管 CDSS 可能具有潜力，但需要进行更大规模的研究，以进一步探索如何最好地部署它们以加强 CKD 治疗。
