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

Abstract

Rationale & Objective: 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. Study Design: A 2×2 randomized controlled pilot trial. Setting & Participants: Primary care provider teams (n = 6) and 137 patients with CKD aged 18 to 75 years from 2 safety-net primary care clinics, 2013 to 2015. Interventions: 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. Outcomes: 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. Results: 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/1.73 m2; 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 > 140/90 mm 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. Limitations: Single health system. Conclusions: 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. Funding: National Institute of Diabetes and Digestive and Kidney Diseases. Trial Registration: ClinicalTrials.gov, number: NCT01530958. Index Words: Chronic kidney disease, randomized controlled trial, registry, self-management support, blood pressure, chronic care model