04 Apr NEJM: UTSW Study Evaluates Whether Practice Facilitators Reduce Hospitalizations in CKD Patients

MedicalResearch.com Interview with:

Dr. Vazquez

Miguel A. Vazquez, MD
Professor of Internal Medicine
University of Texas Southwestern Medical Center

MedicalResearch.com: What is the background for this study?

Response: The main reason to conduct our trial was to improve the care of patients with coexistent chronic kidney disease CKD),  type 2 diabetes and hypertension.   Patients with this triad are at high risk for multiple complications, end stage kidney disease and premature death.   There are effective interventions for these conditions.  Unfortunately, detection and awareness of CKD is low and many patients do not receive interventions that could be beneficial

In our study in patients with the coexistent triad of chronic kidney disease, type 2 diabetes, and hypertension the use of an electronic algorithm to identify patients from the electronic health record and practice facilitators embedded in four large health systems to assist primary practitioners deliver evidence-based care did not lower hospitalizations when compared to usual care.

MedicalResearch.com: What are the main findings?

Response:   Although we did not observe a difference in the primary outcome we believe that the study is an important step in advancing our understanding of how to conduct pragmatic trials embedded within health care systems. The study was a pragmatic clinical trial embedded in four large health care systems.   This approach allows to test an intervention delivered under real-world conditions as part of the care of patients in the health system. It was possible to identify and enroll a large number of patients including members of groups who are usually underrepresented in large clinical trials.  The intervention was delivered across four large health care systems and using various electronic health records.  There was fidelity to delivery of the intervention and robust capture of outcomes.  The study provides lessons on how to test multicomponent interventions in patients with multiple chronic conditions.

MedicalResearch.com: What do you think limits the ability of embedded facilitators to reduce hospitalizations in CKD patients? 

Response:   Practice facilitators are effective to support adoption of evidence-based therapies in primary care practices.   There are various possible reasons that may explain why embedded practice facilitators did not reduce hospitalizations.   It takes time for changes in processes of care to affect some clinical outcomes and the one- year follow up in the study may not have been long enough to observe differences between the groups.    Another consideration is that the intervention could have been more effective if implemented earlier in the course of the disease process.  There could have been also differences in adherence to treatment by patients, referrals to subspecialists or other factors not captured in the study.  There are now some new therapies for patients with CKD, type 2 diabetes and hypertension which could be of additional benefit in this patient population, 

MedicalResearch.com: What recommendations do you have for future research as a results of this study?

Response: We believe that the study provides lessons on how to test multicomponent interventions in patients with multiple chronic conditions. We are hopeful that embedded pragmatic clinical trials can allow rigorous and efficient testing of key questions to continue improving the care of patients with multiple chronic conditions in the future.

Disclosures: I do receive  support from NIH grants ( from NIDDK and NIA).

Citation:

Pragmatic Trial of Hospitalization Rate in Chronic Kidney Disease

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Last Updated on April 4, 2024 by Marie Benz MD FAAD