Decision Support System Helps Treat Uncontrolled Hypertension in CKD

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Implementing a computerized clinical decision support system can decrease systolic blood pressure (SBP) in patients with chronic kidney disease (CKD) and uncontrolled hypertension, according to trial findings.

In the randomized trial of 2026 patients with stage 3-4 CKD and uncontrolled hypertension (, NCT03679247), the clinical decision support group experienced a mean decline in SBP of 14.6 mmHg over 180 days, which was significantly more than the 11.7 mmHg decline in the usual care group, Lipika Samal, MD, MPH, of Brigham and Women’s Hospital in Boston, Massachusetts, and colleagues reported in JAMA Internal Medicine. Mean SBP at baseline was 154.0 mmHg.

The computerized clinical decision support system sent electronic alerts to primary care physicians with orders for initiation or titration of renin-angiotensin-aldosterone system inhibitors, laboratory testing, and nephrology e-consultation based on synthesized electronic health data. For example, a prompt could read “Patient has CKD, 2 SBP values of 140 mmHg or higher, and is on an ACE inhibitor, which could be increased.” Clinicians were required to electronically pledge to follow recommendations about blood pressure management. Those who decided not to follow a specific recommendation for a particular patient had to provide a written justification.

The system increased recognition of undiagnosed CKD and uncontrolled hypertension in patients with pre-existing CKD, increased prescriptions of ACE inhibitors and angiotensin receptor blockers, and increased orders for a basic metabolic panel, and referrals for nephrology electronic consult more so than the usual care group. Significantly more patients in the intervention than usual care group received a recommended clinical action in agreement with the support system: 49.9% vs 34.6%, the investigators reported.

The proportion of patients achieving blood pressure control, however, did not differ significantly between the intervention and control group: 50.4% vs 47.1%. The control group initially received an email with a CKD clinical guideline.

According to Dr Samal’s team, this study is “the first to show a significant positive effect on SBP as a continuous outcome. However, we did not show a significant difference in BP control between study groups.” They attribute the success of the intervention to the behavioral components including precommitment to follow recommendations and justifications when those were not followed.

The study involved 15 primary care practices including 174 primary care physicians. Patients’ mean age was 75.3 years.

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