Interventions to Improve Blood Pressure Control Among Socioeconomically Disadvantaged Patients With CKD: Kidney Awareness Registry and Education Pilot Randomized Controlled Trial

Abstract

Sustainable interventions that enhance chronic kidney disease (CKD) management are not often studied in safety-net primary care, in which populations bear a disproportionate burden of disease and experience translational gaps between research and practice. We tested the feasibility of implementing and the impact of 2 technology-enhanced interventions designed to enhance CKD care delivery. A 2×2 randomized controlled pilot trial. Primary care provider teams (n= 6) and 137 patients with CKD aged 18 to 75 years from 2 safety-net primary care clinics, 2013 to2015. Primary care provider teams were randomly assigned to access a CKD registry with point-of-care notifications and quarterly feedback or a usual-care registry for 12 months. Patients within provider teams were randomly assigned to participate in a CKD self-management support program or usual care for 12 months. We examined recruitment, randomization, and participation in each intervention. We also examined the impact of each intervention and their combination on change in systolic blood pressure (SBP), albuminuria, and patient self-reported behavioral measures after 12 months. Among potentially eligible patients identified using the electronic health record, 24% were eligible for study participation, of whom 35% (n= 137) were enrolled. Mean age was 55 years, 41% were non-English speaking, and 93% were of racial/ethnic minority. Mean baseline estimated glomerular filtration rate was 70.5 (SD= 30.3) mL/min/1.73m2; mean baseline SBP was 131 (SD= 21.8) mm Hg. Nearly 90% of clinicians reported that the CKD registry influenced their CKD management. More than 95% of patients randomly assigned to CKD self-management support engaged regularly with the intervention. Estimated changes in SBP over 1 year were nonstatistically different in each of the 3 intervention groups compared with usual care: (usual care: 0.5 [95% CI,-5.2 to 6.3] mm Hg; CKD registry only:-5.4 [95% CI,-12.2 to 1.4] mm Hg; CKD self-management support only:-6.4 [95% CI,-13.7 to 1.0] mm Hg; and CKD registry plus CKD self-management support:-0.5 [-5.5 to 4.5] mm Hg), though differences were larger among those with baseline SBPs > 140/90mm Hg. Decreases in albuminuria were similarly nonstatistically different in each of the intervention groups compared with usual care. No differences were observed in patient self-reported behaviors. Single health system. Patient and provider interventions to improve CKD care are feasible to implement in low-income settings with promising results among those with uncontrolled blood pressure. National Institute of Diabetes and Digestive and Kidney Diseases. ClinicalTrials.gov, number: NCT01530958.