Group Medical Visits in Heart Failure for Post-Hospitalization Follow-Up

 描述（由申请人提供）： 本研究项目的主要目标是通过对患者的教育、疾病监测和通过共享医疗预约（SMA）进行药物滴定，改善心力衰竭（HF）出院患者的健康状况，减少住院和死亡。研究发现，HF患者的自我护理行为（例如，药物/饮食不依从）和卫生系统因素（例如，护理不协调、有限的获取、缺乏对患者和护理人员的教育）在患者的健康状况和住院风险中发挥了重要作用，以至于50%的再入院被判定为可能/很可能是可预防的。为了解决基于慢性护理模型的患者和系统因素，通过SMA重新设计护理递送可以是提供患者自我管理支持的良好解决方案，同时还在同伴支持的环境中执行疾病监测和药物管理。我们提出了一项随机对照试验，招募HF住院出院后6周内的患者，并将其随机分配至每隔一周接受SMA干预治疗，持续8周，与常规治疗HF相比。我们将在随机化后180天确定，与接受常规治疗的患者相比，参加HF-SMA的HF患者是否：1）通过堪萨斯城心肌病问卷测量的心脏健康状况更好（主要结局）和总体健康状况（EQ 5D，次要结局）; 2）住院或死亡较少，3）中间结局改善：a）HF自我护理行为增加，和B）血浆BNP水平降低。 对于接受HF-SMA的患者，我们还将通过（a）与患者进行面对面访谈和（B）与利益相关者（患者的医生和管理人员）进行电话访谈，确定感知的获益、需要改进的领域、实施的潜在障碍和各研究中心干预的保真度。 研究中心为普罗维登斯VA和凤凰城VA医院，共入组375例患者。所有患者的研究持续时间为180天，从随机化开始。我们将使用分层（入组其他HF护理项目，过去6个月住院<2次，左心室射血分数<40%），区组随机化，每个研究中心区组大小为4，以确保分层变量的平衡。该小组将由一名营养师、护士、健康心理学家、临床药剂师或执业护士组成，没有医生在场（心脏病专家将B叫随到）。会议将首先评估患者的需求，然后进行预先分配的基于主题的疾病自我管理教育，然后进行患者发起的疾病管理讨论，最后进行个性化药物病例管理的分组会议。 我们的研究结果将用于医疗保健管理和系统重新设计，为HF退伍军人提供更好的质量和以患者为中心的护理。长期目标是在小组环境中使用多学科团队方法来管理HF支持定期医生访视，在同伴支持环境中，所有这些都是提供以患者为中心的护理和改善结局所必需的。

 DESCRIPTION (provided by applicant): The primary goal of this research project is to improve the health status and decrease hospitalization and death for patients discharged with heart failure (HF) via education to patients, disease monitoring and medication titration through shared medical appointments (SMAs). Studies have found patient self-care behaviors in HF (e.g. medication/dietary noncompliance) and health system factors (e.g. care discoordination, limited access, lack of education to patients and caregivers) played an important role in patient's health status and hospitalization risk to the extent that 50% of the readmissions were judged to be possibly/probably preventable. To address patient and system factors based on the Chronic Care Model, redesign of care delivery, via SMA's, can be a good solution to provide patient self- management support while also performing disease monitoring and medication management in an environment of peer support. We propose a randomized controlled trial to enroll patients within 6 weeks of discharge from a HF hospitalization and randomized them to receive either SMA intervention every other week for 8 weeks versus usual care for HF. We will determine, at 180 days from randomization, whether HF patients who participate in HF-SMA, as compared to patients who receive usual care: 1) Experience better cardiac health status measured by Kansas City Cardiomyopathy Questionnaire (primary outcome), and overall health status (EQ5D, secondary outcome); 2) Have fewer hospitalization or death and 3) Experience improvement in intermediate outcomes: a) increase in HF Self-Care behavior, and b) decrease in plasma BNP levels. For patients who underwent HF-SMA, we will also determine perceived benefits, areas in need of improvement, potential obstacles of implementation, and fidelity of the intervention across sites, by conducting (a) face-to-face interviews with patients and (b) telephone interviews with stakeholders (physicians of the patients and administrators). The sites will be Providence VA and Phoenix VA hospitals to enroll a total of 375 patients. The study duration will be 180 days for all patients from the time of randomization. We will use stratified (enrollment in other programs for HF care, <2 hospitalizations last 6 months, left ventricular ejection fraction <40%), block randomization with block sizes of 4 in each site to ensure balance of the stratified variables. The team will consist of a nutritionist, nurse, health psychologist an a clinical pharmacist or nurse practitioner, without the presence of a physician (cardiologist will b available on call). The session will start with an assessment of patient needs followed by pre-assigned theme-based disease self-management education, followed by patient-initiated disease management discussion, and conclude with break-out sessions of individualized medication case management. Our study findings will be used in health care management and system redesign to provide better quality and patient centered care for our veterans with HF. The long-term goal is to use a multi-disciplinary team approach in a group setting to manage HF support regular physician visits, in a peer support environment, all of which, are necessary to provide patient- centered care and improve outcomes.