This is a bit of a fascinating article with a great deal to unpack – and rightly published in a prominent journal.
The brief summary – this is a “pragmatic”, open-label, cluster-randomized trial in which a set of interventions designed to increase guideline-concordant care were rolled out via electronic health record tools. These interventions were further supported by “facilitators”, persons assigned to each practice in the intervention cohort to support uptake of the EHR tools. In this specific study, the underlying disease state was the triad of chronic kidney disease, hypertension, and type II diabetes. Each of these disease states has well-defined pathways for “optimal” therapy and escalation.
The most notable feature of this trial is the simple, negative topline result – rollout of this intervention had no reliably measurable effect on patient-oriented outcomes relating to disease progression or acute clinical deterioration. Delving below the surface provides a number of insights worthy of comment:
- The authors could have easily made this a positive trial by having the primary outcome as change in guideline-concordant care, as many other trials have done. This is a lovely example of how surrogates for patient-oriented outcomes must always be critically appraised for the strength of their association.
- The entire concept of this trial is likely passively traumatizing to many clinicians – being bludgeoned by electronic health record reminders and administrative nannying to increase compliance with some sort of “quality” standard. Despite all these investments, alerts, and nagging – patients did no better. As above, since many of these trials simply measure changes in behavior as their endpoints, it likely leaves many clinicians feeling sour seeing results like these where patients are no better off.
- The care “bundle” and its lack of effect size is notable, although it ought to be noted the patient-oriented outcomes here for these chronic, life-long diseases are quite short-term. The external validity of findings demonstrated in clinical trials frequently falls short when generalized to the “real world”. The scope of the investment here and its lack of patient-oriented improvement is a reminder of the challenges in medicine regarding evidence of sufficient strength to reliably inform practice.
Not an Emergency Medicine article, per se, but certainly describes the sorts of pressures on clinical practice pervasive across specialties.
“Pragmatic Trial of Hospitalization Rate in Chronic Kidney Disease”
https://www.nejm.org/doi/full/10.1056/NEJMoa2311708