Overcoming barriers to warfarin patient self-management implementation in the US healthcare system

项目摘要 在美国，接受华法林治疗的患者很少被允许参与患者自我管理(PSM) 这比标准的临床医生指导的华法林治疗更少负担，更便宜，更安全。 国家和国际循证指南小组强烈建议PSM优先于其他华法林 适合患者的管理方法，因为它改善了INR控制，降低了血栓形成的风险，并 死亡率减半而不增加出血风险，并提高患者满意度和生活质量。这个 尚未系统地评估和验证PSM在美国环境中未得到充分利用的原因。我们 将解决这一知识差距，并为提高PSM利用率提供基础信息 美国的医疗体系。我们的目标1将评估和验证PSM的障碍和促进者，并评估他们的 适用于美国医疗保健系统；AIM 2将在美国开发和测试PSM实施战略 使用快速周期研究方法的门诊护理地点；目标3将评估执行情况 (可行性、保真度、采用率)、临床(有效性、安全性、公平性、以患者为中心)和最终用户 (满意度)结果。我们应用的长期目标是提高非卧床的安全性 通过加大PSM的实施力度进行华法林治疗。我们的应用程序支持 AHRQ通过提高用药的安全性和改善整体健康，并专注于一种特定的 感兴趣领域，即实施措施、指标、工具和/或实践的干预(PSM) 确保对在门诊护理环境中接受高风险治疗的个人进行适当的监测 作为抗凝治疗。我们的研究建议以实现科学逻辑模型为指导 纳入众所周知的实施科学框架，以支持具体目标。定性数据 目标1的收集和分析将使用执行综合框架进行组织 研究(CFIR)确定了影响执行的五个领域的决定性框架： 干预、内部设置、外部设置、个人和实施过程。每个内部的构造 该领域提供关于确定和衡量潜在实施障碍或促进者的因素的指导。 目标2中的PSM实施活动将由质量实施框架(QIF)指导，该框架 确定关键实施流程步骤以及与这些步骤相关的具体行动，这些步骤可以 用于实现高质量的PSM实施。执行战略将得到快速周期的支持 由AHRQ基于实践的研究网络开发的研究框架。年的执行成果 AIM 3将使用广为人知的REACH、有效性、采用、实施、维护(RE- Aim)框架。我们将利用类型III混合研究设计来测试PSM实施策略，同时 观察/收集与PSM相关的临床和经济结果的信息。

Project Summary In the US, patients receiving warfarin therapy are rarely allowed to engage in patient self-management (PSM) which is less burdensome, less expensive, and safer than standard clinician-directed warfarin management. National and international evidence-based guideline panels strongly recommend PSM over other warfarin management methods for appropriate patients because it improves INR control, cuts risk of thrombosis and death by half without increasing bleeding risk, and increases patient satisfaction and quality of life. The reasons behind PSM underutilization in US settings have not been systematically assessed and validated. We will address this knowledge gap and provide foundational information for increasing PSM utilization within the US healthcare system. Our Aim 1 will assess and validate barriers and facilitators to PSM and evaluate their applicability to the US healthcare system; Aim 2 will develop and test PSM implementation strategies in US ambulatory care sites using rapid-cycle research methodology; and Aim 3 will assess implementation (feasibility, fidelity, adoption), clinical (effectiveness, safety, equity, patient-centeredness), and end-user (satisfaction) outcomes. The long-term objective of our application is to improve the safety of ambulatory warfarin therapy through increasing the implementation of PSM. Our application supports the mission of the AHRQ by improving the safety of medication and improvement in overall health and focuses on a specified area of interest, namely an intervention (PSM) that implements a measure, metric, tool, and/or practice to ensure appropriate monitoring for individuals receiving high risk treatments in the ambulatory care setting such as anticoagulation therapy. Our research proposal is guided by an implementation science logic model that incorporates well-known implementation science frameworks to support the specific aims. Qualitative data collection and analysis for Aim 1 will be organized using the Consolidated Framework for Implementation Research (CFIR) a determinant framework that identifies five domains influencing implementation: Intervention, Inner Setting, Outer Setting, Individuals, and the Implementation Process. Constructs within each domain provide guidance on factors to identify and measure as potential implementation barriers or facilitators. PSM implementation activities in Aim 2 will be guided by the Quality Implementation Framework (QIF), which identifies the critical implementation process steps and specific actions related to these steps that can be utilized to achieve quality PSM implementation. Implementation strategies will be supported by the rapid-cycle research framework developed by the AHRQ Practice Based Research Network. Implementation outcomes in Aim 3 will be structured using the well-known Reach, Efficacy, Adoption, Implementation, Maintenance (RE- AIM) framework. We will utilize a type III hybrid research design to test PSM implementation strategies while observing/gathering information on PSM-related clinical and economic outcomes.