Clinical Decision Support System May Aid Hypertension Management, Improve Clinical Outcomes in CKD

Lipika Samal, MD, MPH

Credit: Lipika Samal on LinkedIn

Hypertension management in patients with chronic kidney disease (CKD) is of paramount importance for reducing the risk of kidney failure, cardiovascular events, and mortality, but its treatment often remains suboptimal in primary care settings – a computerized clinical decision support system may offer a promising solution.¹

Results from a randomized clinical trial published in JAMA Internal Medicine showcase the viability of a system incorporating behavioral economic principles and human-centered design methods for reducing patients’ systolic blood pressure (SBP) and improving providers’ prescribing habits and other actions for improving patient outcomes.¹

Hypertension is prevalent among as many as 90% of patients with CKD and contributes to disease progression. It is the second leading cause of kidney failure in the US after diabetes, underscoring the importance of its management in this patient population.^2,3

“Despite national efforts to increase awareness of CKD, few patients with stage 3 to 4 CKD are aware of their disease; in addition, hypertension treatment in CKD remains suboptimal in primary care settings,” Lipika Samal, MD, MPH, associate professor of medicine at Harvard Medical School, and colleagues wrote.¹

To assess the impact of a computerized clinical decision support system intervention on the management of uncontrolled hypertension in patients with CKD, investigators enrolled primary care practitioners from 15 hospital-based, ambulatory, and community health center-based clinics and randomly assigned them in a stratified, matched-pair approach to the intervention or usual care.¹

The intervention consisted of a clinical decision support system based on behavioral economic principles and human-centered design methods that delivered tailored, evidence-based recommendations, including initiation or titration of renin-angiotensin-aldosterone system inhibitors. In the control group, the clinical decision support system was operating in silent mode.¹

All patients ≥ 18 years of age who had a visit with a primary care practitioner at any of the intervention practices during the 2 years preceding the first visit during the study intervention period were eligible for inclusion. Investigators enrolled those who had an office visit once the study period began and fulfilled criteria for stage 3 or stage 4 CKD and uncontrolled hypertension.¹

The primary outcome was the change in mean SBP between baseline and 180 days in each study group. Secondary outcomes included blood pressure (BP) control and outcomes, including the percentage of patients who received an action that aligned with the clinical decision support system recommendations.¹

In total, the study included 174 primary care practitioners and 2026 patients who were predominantly female (60.4%) with a mean age of 75.3 (Standard deviation [SD], 0.3) years. Investigators randomly assigned 87 primary care practitioners and 1029 patients to the intervention and 87 primary care practitioners and 997 patients to usual care.¹

Overall, 1714 (84.6%) patients were treated for hypertension at baseline. There were 1623 (80.1%) patients with an SBP measurement at 180 days, including 815 patients in the intervention group and 808 patients in the usual care group. Investigators noted a significant difference in SBP change between groups, with a mean SBP change of −14.6 (95% CI, −13.1 to −16.0) mm Hg in the intervention group compared to −11.7 (95% CI, −10.2 to −13.1) mm Hg in the usual care group (P = .005).¹

Although there was no difference in the percentage of patients who achieved BP control in the intervention group (50.4%; 95% CI, 46.5% to 54.3%) compared with the control group vs (47.1%; 95% CI, 43.3% to 51.0%), more patients who received the study intervention received an action aligned with the clinical decision support recommendations (49.9%; 95% CI, 45.1% to 54.8% vs 34.6%; 95% CI, 29.8% to 39.4%; P < .001). Accordingly, investigators pointed out the percentage of patients who received an order for any ACE, ARB, or thiazide diuretic was significantly greater in the intervention arm than in the usual care group (P <.001).¹

“Further research is needed to understand the persistence of these findings and impact on CKD outcomes, such as cardiovascular disease and progression of kidney disease at the population level,” investigators concluded.¹

References:

1. ^{Samal L, Kilgallon JL, Lipsitz S, et al. Clinical Decision Support for Hypertension Management in Chronic Kidney Disease: A Randomized Clinical Trial. JAMA Intern Med. Published online March 11, 2024. doi:10.1001/jamainternmed.2023.8315}
2. ^{Pugh D, Gallacher PJ, Dhaun N. Management of Hypertension in Chronic Kidney Disease [published correction appears in Drugs. 2020 Sep;80(13):1381]. Drugs. 2019;79(4):365-379. doi:10.1007/s40265-019-1064-1}
3. ^{National Kidney Foundation. High Blood Pressure and Chronic Kidney Disease. Accessed March 14, 2024. https://www.kidney.org/news/newsroom/factsheets/High-Blood-Pressure-and-CKD}