PDF(Pubmed)
Abstract：
BACKGROUND: We hypothesized that multidisciplinary, proactive electronic consultation (MPE) could overcome barriers to prescribing guideline-directed medical therapies (GDMTs) for patients with type 2 diabetes (T2D) and chronic kidney disease (CKD).
METHODS: We conducted an efficacy-implementation pilot study of MPE for T2D and CKD for primary care provider (PCP)-patient dyads at an academic health system. MPE included (1) a dashboard to identify patients without a prescription for sodium-glucose cotransporter-2 inhibitors (SGLT2i) and without a maximum dose prescription for renin-angiotensin-aldosterone system inhibitors (RAASi), (2) a multidisciplinary team of specialists to provide recommendations using e-consult templates, and (3) a workflow to deliver timely e-consult recommendations to PCPs. In-depth interviews were conducted with PCPs and specialists to assess feasibility, acceptability, and appropriateness of MPE and were analyzed using an iterative qualitative analysis approach to identify major themes. Prescription data were extracted from the electronic health record to assess preliminary effectiveness to increase GDMT.
RESULTS: 20 PCPs agreed to participate, 18 PCPs received MPEs for one of their patients with T2D and CKD, and 16 PCPs and 2 specialists were interviewed. Major themes were as follows: appropriateness of prioritization of GDMT for T2D and CKD, acceptability of the content of the recommendations, PCP characteristics impact experience with MPE, acceptability and appropriateness of multidisciplinary collaboration, feasibility of MPE to overcome patient-specific barriers to GDMT, and appropriateness of workflow. At 6 months postbaseline, 7/18 (39%) patients were newly prescribed an SGLT2i, and 7/18 (39%) patients were either newly prescribed or had increased dose of RAASi.
CONCLUSIONS: MPE was an acceptable and appropriate health system strategy to identify and address gaps in GDMT among patients with T2D and CKD. Adopting MPE could enhance GDMT, though PCPs raised feasibility concerns which could be improved with program enhancements, including follow-up e-consults for reinforcement, and administrative support for navigating system-level barriers.
METHODS: We conducted an efficacy-implementation pilot study of MPE for T2D and CKD for primary care provider (PCP)-patient dyads at an academic health system. MPE included (1) a dashboard to identify patients without a prescription for sodium-glucose cotransporter-2 inhibitors (SGLT2i) and without a maximum dose prescription for renin-angiotensin-aldosterone system inhibitors (RAASi), (2) a multidisciplinary team of specialists to provide recommendations using e-consult templates, and (3) a workflow to deliver timely e-consult recommendations to PCPs. In-depth interviews were conducted with PCPs and specialists to assess feasibility, acceptability, and appropriateness of MPE and were analyzed using an iterative qualitative analysis approach to identify major themes. Prescription data were extracted from the electronic health record to assess preliminary effectiveness to increase GDMT.
RESULTS: 20 PCPs agreed to participate, 18 PCPs received MPEs for one of their patients with T2D and CKD, and 16 PCPs and 2 specialists were interviewed. Major themes were as follows: appropriateness of prioritization of GDMT for T2D and CKD, acceptability of the content of the recommendations, PCP characteristics impact experience with MPE, acceptability and appropriateness of multidisciplinary collaboration, feasibility of MPE to overcome patient-specific barriers to GDMT, and appropriateness of workflow. At 6 months postbaseline, 7/18 (39%) patients were newly prescribed an SGLT2i, and 7/18 (39%) patients were either newly prescribed or had increased dose of RAASi.
CONCLUSIONS: MPE was an acceptable and appropriate health system strategy to identify and address gaps in GDMT among patients with T2D and CKD. Adopting MPE could enhance GDMT, though PCPs raised feasibility concerns which could be improved with program enhancements, including follow-up e-consults for reinforcement, and administrative support for navigating system-level barriers.
摘要：
背景：我们假设多学科，主动电子会诊(MPE)可以克服为2型糖尿病(T2D)和慢性肾脏病(CKD)患者开具指南指导药物治疗(GDMT)的障碍.
方法：我们在学术卫生系统中进行了一项针对T2D的MPE和针对初级保健提供者（PCP）-患者二元组的CKD的疗效实施试验研究。MPE包括（1）仪表板，以识别没有钠-葡萄糖协同转运蛋白2抑制剂（SGLT2i）处方和没有肾素-血管紧张素-醛固酮系统抑制剂（RAASi）最大剂量处方的患者，（2）多学科专家团队使用电子咨询模板提供建议，和(3)向PCP提供及时的电子咨询建议的工作流程。与PCP和专家进行了深入访谈，以评估可行性，可接受性,和MPE的适当性，并使用迭代定性分析方法进行分析，以确定主要主题。从电子健康记录中提取处方数据，以评估增加GDMT的初步有效性。
结果：20个PCP同意参与，18名PCP为其中一名患有T2D和CKD的患者接受了MPE，16名PCP和2名专家接受了采访。主要主题如下：T2D和CKD的GDMT优先次序的适当性，建议内容的可接受性，PCP特性影响MPE的经验,多学科合作的可接受性和适当性，MPE克服GDMT患者特异性障碍的可行性，和工作流程的适当性。基线后6个月，7/18（39%）患者新开SGLT2i处方，和7/18(39%)患者是新处方或增加RAASi剂量.
结论：MPE是一种可接受且适当的卫生系统策略，可用于识别和解决T2D和CKD患者中GDMT的差距。采用MPE可以增强GDMT，尽管PCP提出了可行性问题，这些问题可以通过程序增强来改善，包括后续的增援电子咨询，以及对导航系统级障碍的行政支持。
方法：我们在学术卫生系统中进行了一项针对T2D的MPE和针对初级保健提供者（PCP）-患者二元组的CKD的疗效实施试验研究。MPE包括（1）仪表板，以识别没有钠-葡萄糖协同转运蛋白2抑制剂（SGLT2i）处方和没有肾素-血管紧张素-醛固酮系统抑制剂（RAASi）最大剂量处方的患者，（2）多学科专家团队使用电子咨询模板提供建议，和(3)向PCP提供及时的电子咨询建议的工作流程。与PCP和专家进行了深入访谈，以评估可行性，可接受性,和MPE的适当性，并使用迭代定性分析方法进行分析，以确定主要主题。从电子健康记录中提取处方数据，以评估增加GDMT的初步有效性。
结果：20个PCP同意参与，18名PCP为其中一名患有T2D和CKD的患者接受了MPE，16名PCP和2名专家接受了采访。主要主题如下：T2D和CKD的GDMT优先次序的适当性，建议内容的可接受性，PCP特性影响MPE的经验,多学科合作的可接受性和适当性，MPE克服GDMT患者特异性障碍的可行性，和工作流程的适当性。基线后6个月，7/18（39%）患者新开SGLT2i处方，和7/18(39%)患者是新处方或增加RAASi剂量.
结论：MPE是一种可接受且适当的卫生系统策略，可用于识别和解决T2D和CKD患者中GDMT的差距。采用MPE可以增强GDMT，尽管PCP提出了可行性问题，这些问题可以通过程序增强来改善，包括后续的增援电子咨询，以及对导航系统级障碍的行政支持。
