Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA.
Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
J Gen Intern Med. 2020 Nov;35(Suppl 2):849-869. doi: 10.1007/s11606-020-06103-7. Epub 2020 Oct 26.
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.
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.
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.
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.
CRD42018102441.
慢性肾脏病（CKD）广泛存在，与发病率和死亡率相关，但通过及时实施基于证据的策略（包括控制血压[BP]）可能会减轻其影响。然而，目前仍然存在证据与实践之间的差距。我们综合了针对初级保健中 CKD 患者高血压管理的以临床医生为导向的干预措施的证据。
电子数据库和相关出版物被检索以获取相关研究。我们使用一个概念模型来解决干预措施的异质性。我们对血压（BP）结果的干预措施进行了定量综合分析，并对其他与 CKD 相关的临床结果进行了叙述性综合分析。计划的亚组分析按（1）研究设计（随机对照试验[RCT]或非随机研究[NRS]）；（2）干预类型（符合指南的决策支持、共同护理、药剂师导向）；和（3）行为/实施理论的使用进行。
在筛查的 2704 篇手稿中，有 73 篇进行了全文审查；22 篇符合纳入标准。15 项研究报告了血压目标的达标情况，6 项研究报告了收缩压的降低情况。在 RCT 中，所有干预措施对血压控制均有显著效果，（汇总 OR 1.21；95%CI 1.07 至 1.38）。按干预类型进行的亚组分析显示，符合指南的决策支持具有显著效果（汇总 OR 1.19；95%CI 1.12 至 1.27），而共同护理（汇总 OR 1.71；95%CI 0.96 至 3.03）或药剂师导向的干预措施（汇总 OR 1.04；95%CI 0.82 至 1.34）则没有显著效果。RCT 和 NRS 的汇总分析结果也得到了复制。五项纳入研究显示收缩压显著降低（汇总 WMD-3.86；95%CI-7.2 至-0.55）。使用行为/实施理论没有影响，而 RCT 比 NRS 的效果量更小。
与符合指南的决策支持一起使用的以过程为导向的实施策略是一种很有前途的实施方法。更好的实施报告指南将能够更有效地综合纳入初级保健的 CKD 临床干预措施的疗效。
PROSPERO 注册号：CRD42018102441。
