Ebp 1748-5908-8-88
Ebp 1748-5908-8-88
Ebp 1748-5908-8-88
Abstract
Background: Chronic kidney disease (CKD) and end stage renal disease (ESRD) are steadily increasing in prevalence
in the United States. While there is reasonable evidence that specific activities can be implemented by primary care
physicians (PCPs) to delay CKD progression and reduce mortality, CKD is under-recognized and undertreated in
primary care offices, and PCPs are generally not familiar with treatment guidelines. The current study addresses the
question of whether the facilitated TRANSLATE model compared to computer decision support (CDS) alone will
lead to improved evidence-based care for CKD in primary care offices.
Methods/Design: This protocol consists of a cluster randomized controlled trial (CRCT) followed by a process and
cost analysis. Only practices providing ambulatory primary care as their principal function, located in non-hospital
settings, employing at least one primary care physician, with a minimum of 2,000 patients seen in the prior year,
are eligible. The intervention will occur at the cluster level and consists of providing CKD-specific CDS versus
CKD-specific CDS plus practice facilitation for all elements of the TRANSLATE model. Patient-level data will be
collected from each participating practice to examine adherence to guideline-concordant care, progression of
CKD and all-cause mortality. Patients are considered to meet stage three CKD criteria if at least two consecutive
estimated glomerular filtration rate (eGFR) measurements at least three months apart fall below 60 ml/min. The
process evaluation (cluster level) will determine through qualitative methods the fidelity of the facilitated TRANS-
LATE program and find the challenges and enablers of the implementation process. The cost-effectiveness analysis
will compare the benefit of the intervention of CDS alone against the intervention of CDS plus TRANSLATE (practice
facilitation) in relationship to overall cost per quality adjusted years of life.
Discussion: This study has three major innovations. First, this study adapts the TRANSLATE method, proven
effective in diabetes care, to CKD. Second, we are creating a generalizable CDS specific to the Kidney Disease
Outcome Quality Initiative (KDOQI) guidelines for CKD. Additionally, this study will evaluate the effects of CDS
versus CDS with facilitation and answer key questions regarding the cost-effectiveness of a facilitated model for
improving CKD outcomes. The study is testing virtual facilitation and Academic detailing making the findings
generalizable to any area of the country.
Trial registration: Registered as NCT01767883 on clinicaltrials.gov
Keywords: Chronic kidney disease, Practice based research networks, Practice facilitation, Academic detailing,
Computer decision support
* Correspondence: chetfox@gmail.com
1
Department of Family Medicine, State University of New York – University at
Buffalo, 77 Goodell St, Buffalo, NY 14203, USA
Full list of author information is available at the end of the article
© 2013 Fox et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Fox et al. Implementation Science 2013, 8:88 Page 2 of 9
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(n = 48,620). Only randomizations that were balanced on the study. Computer Integrated Networks of America
stratification variables were retained (n = 1,728). For each (CINA), Health Metrics Systems (HMS), and an EMR
randomization, a balance criterion (defined as the sum of with integrated CDS Medent. All practices will receive
squared differences on standardized variables between one session of introductory academic detailing [38]
control and intervention groups) was computed. After concerning the rationale for the algorithms. They will
examining the distribution of the balance criterion, a max- also be provided related technical support on request.
imum allowable difference between the groups was Facilitated practices will receive the CKD-specific CDS,
established and an optimal set of randomizations identi- as well as a practice facilitator to assist them in the im-
fied (n = 136). From this set, one was chosen using a ran- plementation of the full TRANSLATE model (Table 1).
dom number generator and practices were assigned to
treatment or control arms. This process was repeated for Facilitation protocol
the next group of seven practices, including a dummy The facilitators' overall role is to help the practices im-
practice in the randomization procedure to accommodate plement the TRANSLATE model to improve guideline-
the uneven number of practices. The remaining practices concordant care for CDK. The facilitator will assist with
will be randomized using the same protocol. As with all the site coordination, physician champion's needs, audit
CRCTs, patients are not randomized per se; they are and feedback, team approach, and education. Two prac-
assigned to treatment conditions along with the medical tice facilitators are each assigned to half of the CDS+
practices in which they receive care. facilitation practices. Throughout the course of the inter-
vention period, the facilitators will engage in virtual in-
Power analysis teractions with the practices, in which they will work
Given the CKD national prevalence rate of 13% and an with practice quality improvement (QI) teams to identify
expected average of 5,500 active patients per practice, and solve issues specifically related to their care of
we expect roughly 715 CKD patients per practice (this patients with CKD and form and maintain relationships
estimate is supported by a recent analysis of >110,000 with each practice. Facilitation objectives include: assis-
individuals with stage three or four CKD drawn from ting practices in setting goals to implement CKD
over 100 DARTNet practices.) With 18 practices per guidelines; helping practice teams, strategize, test, and
arm and a minimum of 200 patients per practice implement change; facilitating meetings and fostering a
(smallest practice estimated at 2,000 patients with a con- continuous QI culture; serving as a liaison for data and
servative 10% prevalence of CKD over life of study) there performance feedback; and sharing best practices and
will be a minimum of 3,600 patients per arm (actual linking intervention practices.
expected sample size is over 14,000 per arm.) A sample Due to the national scope of this project, facilitation
size of 3,600 per arm will provide >80% power to detect contacts will occur ‘virtually’ using videoconferencing
a 0.18 effect size difference between two arms at a single (GoToMeeting®), phone, and e-mail. General communi-
time point if the intra-class correlation (ICC) is 3%. This cation will entail a minimum of once monthly telecon-
effect size was assumed based on previous results from ferences with each practice’s site coordinator to review
the diabetes TRANSLATE study [32]. In terms of change the status of the project, monthly virtual QI team meet-
over time, a sample size of 3,600 will provide >80% ings, monthly calls between the academic mentors and
power to detect a small linear trend effect, increasing the lead physician, periodic learning collaboratives, and
from 0 at baseline to 0.2 standard deviation (SD) at final a benchmarking webinar every six months with the aca-
follow up, with four observations per person and an ICC demic detailing team.
of 3%, with a random effects structure with random
intercept and random slope [37]. Data collection
Clinical data
Intervention design From practice EHRs, we will collect the measurements
Four elements of the TRANSLATE method will be outlined in Table 2. Medication fulfillment data will be
implemented in both groups, while the remaining ones collected from Surescripts RxHub through CINA or the
will apply to facilitated practices only. All interventions practice EHR. Death will be determined from informa-
will occur at the cluster level, and there will be no tion in practice EHRs or from linkages to the National
randomization or specific intervention undertaken for Death Registry. We will check for deaths among patients
individual patients. The CDS-only practices will have who have not made any visits in the prior 12 months in
CKD decision support algorithms based on the Kidney the first two years of the intervention and in the prior
Disease Outcomes Quality Initiative (KDOQI guidelines six months in the final year of the intervention. Medi-
added to their existing CDS. There will be three separate care claims data will be obtained before and after the
vendors that will be providing point of care support for intervention to allow for a proper cost analysis.
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Table 1 Translate elements by intervention arm Table 1 Translate elements by intervention arm
TRANSLATE elements that will be used in both arms (Continued)
Target: Common targets will be set for all practices and The academic mentor will review the
tracked through the CKD tool. The CDS-only practice’s data and participate in a quarterly
practices will receive a quick reference guide for videoconference with either the study
the treatment of CKD coordinator or the lead clinician to review
Registry and CINA created a CKD registry and will maintain it progress on the project.
reminder systems throughout the study period. Point-of-care decision
support specific to CKD will be provided to practice
staff and physicians prior to patient visits. Process evaluation
Administrative buy-in Obtain consent from each practice and all To determine the effectiveness of the TRANSLATE ele-
practice sites asked to identify a physician
champion and site coordinator to oversee study
ments, it is crucial to first determine the degree of adop-
implementation at their site. tion by the practice, and then systematically document
Network Information The information systems (EHRs and CDS) the challenges and enablers of the implementation
systems will be used to create system level reports process, including the role of facilitation and the con-
across all practices. textual factors that contribute to success. Qualitative
TRANSLATE element that will be used only in facilitated CDS measures will be collected in tandem with the imple-
practices
mentation of facilitated TRANSLATE elements to sup-
Site coordination A site coordinator at each practice will assemble
a quality improvement (QI) team that will meet
port real-time learning and a reiterative process of
monthly to review performance data regarding evaluation (Table 3).
CKD. The site coordinator will also work with the Semi-structured interviews will be conducted with the
clinicians and practice staff to implement
workflow changes such as pre-visit planning,
physician champions at baseline and endpoint, asking
standing orders, and patient education materials
to improve efficiency of disease management. In
addition, the site coordinator will be in contact Table 2 Clinical data elements
with the practice facilitator by videoconference Data element Measure type
for assistance and advice.
Year of birth Numerical
Local physician This person will be the clinician leader and
champion educator for other providers in each practice. Gender M/F
Responsibilities will include supporting the site Race/ethnicity Standard major groups and Other
coordinator and the QI team. This physician will
be in contact with the academic mentor for the Current smoking Current, never, past
practice regarding clinical questions about CKD Height and weight/BMI Hgt, wgt actual
and will participate in learning collaboratives with
the site coordinator. Total visits/encounters Encounter records
Audit and feedback Practice, individual provider, and patient-level Hemoglobin Numerical result
outcome reports for the intervention practices
HDL Numerical result
will be generated through CINA regarding the
seven performance measures (BP, HbAIC, LDL, LDL-C Numerical result
use of ACE/ARB, referral to a nephrologist,
smoking cessation and avoidance of NSAID or Triglycerides Numerical result
Cox-2) and will be reviewed by the team. Creatinine Numerical result
Reports will also be reviewed quarterly with
the practice facilitator by videoconference. The AST Numerical result
videoconference will allow the facilitator to ALT Numerical result
learn what worked in each practice and to
share what other practices have implemented HbA1c Numerical result
successfully. 25 OH Vitamin D Numerical result
Team approach A quality improvement (QI) team consisting of
Electrolytes Numerical result
the local physician champion, site coordinator
and nursing, front office, and administrative staff Serum phosphorous Numerical result
will meet monthly to review progress of the CKD
project. Workflow changes will be recommended PTH intact Numerical result
and tested. All medications Coded (NDC)/RxNorm
Education An educational program using academic All diagnosis – active & inactive ICD-9
detailing and practice facilitation and
videoconferencing will be utilized to support Blood pressure Systolic and diastolic
the practices’ efforts. All facilitated practices Estimated GFR Calculated value
will be assigned an academic practice mentor.
This mentor will be available to the office Urine albumin/creatinine ratio Calculated value
physician champion and practice coordinator
Medicare insurance coverage Flag for medicare insurance
to answer any questions and discuss plans.
Nephrologists referrals Referral records (when available)
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about their care of patients with CKD and workflow pro- measure the cost of providing CKD services. The investi-
cesses in their office. Members of the evaluation team gators have created and used a spreadsheet and guide-
will also conduct site visits at endpoint with both inter- line for collecting cost data from practices for previous
vention and comparator practices. studies [39,40]. The practice facilitation activities of
E-mail and other communication between practice TRANSLATE are expected to lead to more costs in the
facilitators and the sites will be analyzed by the evalu- intervention practices. The cost of training clinic practices
ation team. Facilitators will also collect notes of meet- to use the CDS system and functions of TRANSLATE will
ings, and practice activities; and submit this information also be included into this type of cost, and the cost of
to the evaluation team on a regular basis. training (time) will be measured based on the hourly
wages of physician or medical staff. The cost of treating
Cost-effectiveness analysis CKD and other healthcare costs for patients will be based
The hypothesis is that the intervention of CDS plus the on the claims data that we acquire from DARTNet.
facilitated-TRANSLATE is more cost-effective than the
intervention of CDS alone, so the economic analysis will Data analysis
focus on the TRANSLATE elements in delaying CKD Clinical data
progression and reducing mortality due to CKD in the The effectiveness measures will include the degree of
practice settings of primary care physicians. Because evidence-based guideline-concordant care for CKD pa-
there is not a true control group (no clinic practice has tients (a patient-level score based on the percentage of
no intervention), the proposed project will examine the goals achieved); CKD progression for patients with stage
relative costs of these interventions. three and four CKD; and all-cause mortality rate.
Three types of costs will be included into the total
costs of each intervention: the cost of providing services Data analysis for hypothesis 1.1 (degree of evidence-based
in the clinic practices; the cost of treating CKD; and the care)
other healthcare expenses for patients. We plan to sur- The primary outcome for this analysis will be a patient-
vey a sample of randomly selected practice clinics to level score based on the percentage of goals achieved.
Fox et al. Implementation Science 2013, 8:88 Page 7 of 9
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Each goal will be assessed using EHR data for the previ- more cost-effective. Because of the available claims data,
ous year (or part of the year in which the patient is electronic medical records data, and mortality data from
eligible) at baseline, 12 months, 24 months, and 36 the National Death Index, the analysis will calculate the
months. Secondary analyses will examine each outcome quality-adjusted life years (QALYs) lost due to CKD for
individually using all available data and continuous mea- both interventions. The QALYs will be the most im-
sures (e.g., SBP, HbA1c, LDL) or dichotomous measures portant effectiveness measure in the economic ana-
(ACE/ARB, referral, smoking, NSAIDS). The structure lysis, because QALYs can be valued as a dollar
of the data is hierarchical (patients nested within prac- amount. In the United States, $50,000 per QALY is a
tices) and longitudinal (repeated assessments on patients decision rule that is often used to guide interpretation
at baseline, 12, 24, and 36 months). of cost-effectiveness analyses. We will also do sensi-
tivity analysis by replacing this decision rule with
Data analysis for hypothesis 2.1 (CKD progression) $25,000 or $100,000. We will compare the effective-
The outcome for this analysis will be eGFR measurements ness (dollar values of QALYs) with the cost, and de-
over time. There will be multiple eGFR measures per pa- termine whether the effectiveness is larger than the
tient over the duration of the study. We will use general cost for each intervention. If the effectiveness is lar-
linear mixed-effects models to estimate the rate of decline ger than the cost, these interventions will have cost
in eGFR (random intercept, random slope) and the degree savings. If both interventions will produce cost sav-
to which the baseline covariates predict eGFR. Time for ings, the proposed project will compare the cost sav-
each observation will be coded as days since baseline, ings for these two interventions and determine which
converted to months to aid interpretability. The primary intervention has a high cost saving amount.
hypothesis of difference in slope between treatment
groups, adjusting for socio-demographic and clinical co- Trial status
variates, will be tested. Recruitment is ongoing. The first wave of practices was
recently randomized, and the official intervention period
Data analysis for hypothesis 2.2 (all-cause mortality) began these practices in January of 2013. Initial baseline
All-cause mortality will be confirmed using the National data are being collected (Additional file 1). Data analysis
Death Index to determine the exact date of death. The out- has not yet occurred. We anticipate that we will reach
come for the analysis will be time from baseline to death. full recruitment (36 practices) and all practices will have
Patients who are alive at the end of the study period will be entered the intervention (allowing a minimum of 18
censored at the end of the follow-up time. Assumptions of months of intervention) by December of 2013. The trial
the proportional hazards model will be checked for each is registered as NCT01767883 on clinicaltrials.gov.
variable. Covariates will include baseline eGFR, defined as
the mean of the last two eGFRs prior to study entry, as well Discussion
as socio-demographic and clinical characteristics. Limitations
Some data elements like nephrology referral may be dif-
Process evaluation ficult to collect if they are entered as free text and not as
Qualitative data for the process evaluation will be order entry. The practices will be worked with individu-
analyzed using an immersion-crystallization approach ally to try and overcome this. We may have difficulty
[41,42]. This content-driven approach allows the data to obtaining Medicare claims data in all practices, so we
speak for itself, as researchers immerse themselves in the may have to use a sample to complete this. Quality
data repeatedly to identify themes that emerge [41]. of life measures may be difficult to obtain for cost-
Themes are identified around concepts that are expressed effectiveness evaluation. This too, may have to be done
repeatedly in the text and constantly compared back to with a sub sample. We originally did not block rando-
the data to ensure that they represent the data accurately. mize within organizations, but two organizations were
Once themes are identified using this method, an add- found that were highly integrated in how they accom-
itional step in the analysis will be to compare the themes plished QI, so we had to change to block randomization
with the elements of the TRANSLATE model to deter- for the groups that had more integrated QI plans, other-
mine how well the data complement the interventional wise there would be cross contamination and a dilution
model and how the data can illuminate the process of of a positive effect of facilitation.
practice adoption of each element.
Innovation and potential impact
Cost-effectiveness analysis This study has three major innovations. First, this study
Analysis will compare the effectiveness-cost ratios be- adapts the TRANSLATE method, proven effective in
tween the two arms to examine which intervention is diabetes care [32], to CKD which, by definition, is a
Fox et al. Implementation Science 2013, 8:88 Page 8 of 9
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complex condition usually presenting with other co- Systems; KDOQI: National Kidney Foundation Kidney Disease Outcomes
morbidities. Successful application of the TRANSLATE Quality Initiative; PCP: Primary care physician; QALY: Quality adjusted years of
life; QI: Quality improvement.
model to complex disease conditions such as CKD will
demonstrate the viability of this model for aiding prac- Competing interests
tices in practice transformation and in treatment of pa- The authors declare no potential conflicts of interest with respect to the
research, authorship, or publication of this article.
tients with other complex co-morbid conditions. Our
TRANSLATE framework also incorporates an imple- Authors’ contributions
mentation team that includes a clinician champion, site CF is the principal investigator and responsible for the concept and design. BV
coordinator, and an administrator to allocate resources contributed to the design of the process evaluation and drafted the manuscript.
LK designed the process evaluation and reviewed the manuscript critically for
and guide and oversee implementation progress. It uti- content. MD designed the randomization protocol and statistical analysis plan
lizes information technology systems such as EMR or and reviewed the manuscript critically for content. HF designed the cost-effecti-
middleware programs to produce registries to facilitate the veness analysis and reviewed the manuscript critically for content. WP contribu-
ted to the content and design of the study and reviewed the manuscript
identification of high-risk patients and generate perform- critically for content. KK contributed to the design of the facilitation intervention
ance reports to provide data for ongoing feedback. In and the process evaluation and reviewed the manuscript critically for content.
future projects, this framework will be used to assess the JV contributed to the content and design of the study and reviewed the
manuscript critically for content. NL contributed to the overall protocol
readiness of practices to participate in QI projects, and to development and standardization and reviewed the manuscript critically for
help diagnose why a project may be failing to improve out- content. KP contributed to the concept and design of the study. All authors
comes, thereby allowing for mid-course corrections. read and approved the final manuscript.
9. Gooch K, Culleton BF, Manns BJ, Zhang J, Alfonso H, Tonelli M, Frank C, health record-based alerts on influenza vaccination for children with
Klarenbach S, Hemmelgarn BR: NSAID use and progression of chronic asthma.[see comment]. Pediatrics 2009, 124:159–169.
kidney disease. Elsevier 2007, 120:280–280. 31. Bryan C, Boren SA, Bryan C, Boren SA: The use and effectiveness of electronic
10. Weissman AJ, Ross PS, Nathan DM, Genuth S, Lachin J, Cefalu WT: Intensive clinical decision support tools in the ambulatory/primary care setting: a
diabetes treatment and cardiovascular disease. Mass Med Soc 2006, systematic review of the literature. Inform Prim Care 2008, 16:79–91.
354:1751. 32. Peterson KA, Radosevich DM, O’Connor PJ, Nyman JA, Prineas RJ, Smith SA,
11. Bakris GL, Weir MR, Shanifar S, Zhang Z, Douglas J, van-Dijk DJ, Brenner BM: Arneson TJ, Corbett VA, Weinhandl JC, Lange CJ, Hannan PJ: Improving
Effects of blood pressure level on progression of diabetic nephropathy: diabetes care in practice: findings from the TRANSLATE trial.
results from the RENAAL study. Am Med Assoc 2003, 163:1555. Diabetes Care 2008, 31:2238–2243.
12. Shepherd J, Kastelein JJ, Bittner V, Deedwania P, Breazna A, Dobson S, 33. Nagykaldi Z, Mold JW, Robinson A, Niebauer L, Ford A: Practice facilitators and
Wilson DJ, Zuckerman A, Wenger NK, Investigators TNT, et al: Intensive lipid practice-based research networks. J Am Board Fam Med 2006, 19:506–510.
lowering with atorvastatin in patients with coronary heart disease and 34. Glynn RJ, Brookhart MA, Stedman M, Avorn J, Solomon DH: Design of
chronic kidney disease: the TNT (Treating to New Targets) study. cluster-randomized trials of quality improvement interventions aimed at
J Am Coll Cardiol 2008, 51:1448–1454. medical care providers. Med Care 2007, 45:S38–43.
13. Fox CH, Brooks A, Zayas LE, McClellan W, Murray B: Primary care 35. Kraschnewski JL, Keyserling TC, Bangdiwala SI, Gizlice Z, Garcia BA, Johnston
physicians’ knowledge and practice patterns in the treatment of chronic LF, Gustafson A, Petrovic L, Glasgow RE, Samuel-Hodge CD: Optimized
kidney disease: an Upstate New York Practice-based Research Network probability sampling of study sites to improve generalizability in a
(UNYNET) study. J Am Board Fam Med 2006, 19:54–61. multisite intervention trial. Prev Chronic Dis 2010, 7:A10.
14. Boulware LE, Troll MU, Jaar BG, Myers DI, Powe NR: Identification and 36. SAS (R) V 9.3 edition. Cary, NC: SAS Institute, Inc; 2011.
referral of patients with progressive CKD: a national study. Am J Kidney 37. Hedeker D, Gibbons RD, Waternaux C: Sample size estimation for
Dis 2006, 48:192–204. longitudinal designs with attrition. Journal of Educational and Behaviorial
15. Agrawal V, Ghosh AK, Barnes MA, McCullough PA: Awareness and knowledge Statistics 1999, 24:70–93.
of clinical practice guidelines for CKD among internal medicine residents: a 38. Soumerai SB, Avorn J: Principles of educational outreach (‘academic
national online survey. Elsevier Inc 2008, 52:1061–1069. detailing') to improve clinical decision making. Am Med Assoc 1990, 263:549.
16. Rogers E: Diffusion of innovations. New York: Free Press; 1983. 39. Cohen DJ, Crabtree BF, Etz RS, Balasubramanian BA, Donahue KE, Leviton
17. Committee on Quality of Health Care in America IoM: Crossing the Quality LC, Clark EC, Isaacson NF, Stange KC, Green LW: Fidelity versus flexibility:
Chasm: A New Health System for the 21st Century. Washington DC: National translating evidence-based research into practice. Am J Prev Med 2008,
Academy Press; 2001. 35:S381–389.
18. Jaen CR, Stange KC, Nutting PA: Competing demands of primary care: a 40. Dodoo MS, Krist AH, Cifuentes M, Green LA: Start-up and incremental
model for the delivery of clinical preventive services. J Fam Pract 1994, practice expenses for behavior change interventions in primary care.
38:166–171. Am J Prev Med 2008, 35:S423–430.
19. Ostbye T, Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL, Ostbye 41. Borkan J: Immersion/Crystallization. In Doing Qualitative Research Second
T, Yarnall KSH, Krause KM, Pollak KI, et al: Is there time for management of edition. Edited by Crabtree BF, Miller WL. Thousand Oaks: Sage Publications,
patients with chronic diseases in primary care? Ann Fam Med 2005, Inc; 1999:179–194.
3:209–214. 42. Miller W, Crabtree B: Clinical research: a multimethod typology and
20. Oxman AD, Thomson MA, Davis DA, Haynes RB: No magic bullets - a qualitative road map. In Doing qualitative research. 2nd edition. Edited by Miller
systematic review of 102 trials of interventions to improve professional W, Crabtree B. Thousand Oaks, California: Sage Publications; 1999:179–194.
practice. Can Med Assoc J 1995, 153:1423–1431.
21. Berwick DM: A user’s manual for the IOM’s ‘quality chasm’ report. doi:10.1186/1748-5908-8-88
Health Aff 2002, 21:80–90. Cite this article as: Fox et al.: Improving evidence-based primary care
22. Lenfant C: Clinical research to clinical practice—lost in translation? for chronic kidney disease: study protocol for a cluster randomized
control trial for translating evidence into practice (TRANSLATE CKD).
N Engl J Med 2003, 349:868–874.
Implementation Science 2013 8:88.
23. Bodenheimer T, Wagner EH, Grumbach K: Improving primary care for
patients with chronic illness. JAMA 2002, 288:1775–1779.
24. Bodenheimer T, Wagner EH, Grumbach K: Improving primary care for
patients with chronic illness: the chronic care model, Part 2. JAMA 2002,
288:1909–1914.
25. Garg AX, Adhikari NK, McDonald H, Rosas-Arellano MP, Devereaux PJ,
Beyene J, Sam J, Haynes RB, Garg AX, Adhikari NKJ, et al: Effects of
computerized clinical decision support systems on practitioner
performance and patient outcomes: a systematic review. JAMA 2005,
293:1223–1238.
26. Cleveringa FG, Gorter KJ, van den-Donk M, Rutten GE, Cleveringa FGW,
Gorter KJ, van den-Donk M, Rutten GEHM: Combined task delegation,
computerized decision support, and feedback improve cardiovascular
risk for type 2 diabetic patients: a cluster randomized trial in primary
care. Diabetes Care 2008, 31:2273–2275.
27. Wells S, Furness S, Rafter N, Horn E, Whittaker R, Stewart A, Moodabe K, Submit your next manuscript to BioMed Central
Roseman P, Selak V, Bramley D, et al: Integrated electronic decision support and take full advantage of:
increases cardiovascular disease risk assessment four fold in routine
primary care practice. Eur J Cardiovasc Prev Rehabil 2008, 15:173–178.
• Convenient online submission
28. Hicks LS, Sequist TD, Ayanian JZ, Shaykevich S, Fairchild DG, Orav EJ,
Bates DW, Hicks LS, Sequist TD, Ayanian JZ, et al: Impact of computerized • Thorough peer review
decision support on blood pressure management and control: a • No space constraints or color figure charges
randomized controlled trial. J Gen Intern Med 2008, 23:429–441.
29. Emery J, Morris H, Goodchild R, Fanshawe T, Prevost AT, Bobrow M, Kinmonth • Immediate publication on acceptance
AL, Emery J, Morris H, Goodchild R, et al: The GRAIDS Trial: a cluster randomised • Inclusion in PubMed, CAS, Scopus and Google Scholar
controlled trial of computer decision support for the management of familial • Research which is freely available for redistribution
cancer risk in primary care. Br J Cancer 2007, 97:486–493.
30. Fiks AG, Hunter KF, Localio AR, Grundmeier RW, Bryant-Stephens T, Luberti
AA, Bell LM, Alessandrini EA, Fiks AG, Hunter KF, et al: Impact of electronic Submit your manuscript at
www.biomedcentral.com/submit