SWitching to Appropriate Prescription in Cardiovascular-Kidney-Metabolic Syndrome

SWAP-CKM (SWitching to Appropriate Prescription in Cardiovascular-Kidney-Metabolic Syndrome) is a pragmatic, cluster-randomized clinical trial designed to evaluate whether electronic health record (EHR)-based alerts can improve medication prescribing among adults with cardiovascular, kidney, and metabolic (CKM) conditions. The study will include all eligible adult patients receiving care within Kaiser Permanente Northern California (KPNC) who have CKM conditions and opportunities for therapeutic medication substitution. Fifteen service areas are randomly assigned to either an intervention group or a usual care group. Clinicians in the intervention group will receive EHR-based Best Practice Advisories (BPAs) identifying opportunities to replace potentially inappropriate medications with guideline-recommended therapies. The intervention may also include audit-and-feedback reports to support medication optimization. Clinicians retain full discretion over treatment decisions. The primary outcome is the proportion of eligible therapeutic optimization opportunities achieved at 9 months. Secondary outcomes include medication initiation and discontinuation, medication optimization at 18 months, and polypharmacy burden.

Inclusion Criteria: * Age \>=18 years * Presence of appropriate CKM condition * Eligible for at least one therapeutic swap * Outpatient encounter, including in-person or telehealth care, with an eligible clinician during the study period. Exclusion Criteria: * Membership at KPNC \< 6 months * Currently on dialysis * Receiving hospice care * Prior history of LVAD, heart transplantation, or any solid organ transplantation