Expanded Role of Primary Care Pharmacists in the Management of Heart Failure

扩大初级保健药剂师在心力衰竭治疗中的作用

• 批准号: 10425916
• 负责人: Paul Heidenreich
• 金额: --
• 依托单位: VETERANS ADMIN PALO ALTO HEALTH CARE SYS
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-10-01 至 2022-09-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10425916
• 关键词: Address; Admission activity; Adrenergic beta-Antagonists; African American population; Ambulatory Care Facilities; Angiotensin Receptor; Angiotensin-Converting Enzyme Inhibitors; Appointment; Businesses; Cardiology; Caring; Clinic; Communities; Complex; Dangerousness; Dose; Emergency department visit; Employee Engagement; Evaluation; Evidence based practice; Feedback; Free Will; Guidelines; Health Services Accessibility; Health system; Healthcare Systems; Heart failure; Hospitalization; Hospitals; Improve Access; Investments; Knowledge; Leadership; Learning; Manuals; Measures; Medical; Medical center; Medication Management; Methods; Monitor; Morbidity - disease rate; Outcome; Patients; Pharmaceutical Preparations; Pharmacists; Pharmacy facility; Primary Health Care; Protocols documentation; Provider; Quality of Care; Recording of previous events; Reporting; Role; Safety; Site; Standardization; Testing; Time; Titrations; Veterans; Wait Time; Work; adverse drug reaction; barrier to care; base; care outcomes; care providers; cost; dashboard; hospital readmission; implementation cost; implementation facilitation; implementation outcomes; implementation strategy; improved; innovation; meetings; member; mortality; operation; patient population; pharmacy benefit; pilot test; primary outcome; programs; randomized trial; satisfaction; side effect

Justification. Heart failure (HF) is a common condition in the VA, with high morbidity and mortality. Accordingly, HF hospitalization and mortality are a focus of VA Safety Analytics for Improvement and Learning (SAIL). Furthermore, HF medical treatment is complex as there are now four classes of medications known to independently prolong survival and are recommended to be used together (five for African Americans). Several medications require titration to recommended doses while monitoring for uncommon but dangerous side effects. Given the complexity of treatment and the insufficient number of cardiologists to manage this large patient population, standardized medication initiation and titration of medications by non-physicians has been tested as an adjunct to current primary care practice of patient aligned care teams (PACT). Pharmacist medication initiation and titration of medications has been found to improve recommended care in multiple randomized trials. However, few VA sites have implemented medication initiation and titration of medications for HF by PACT pharmacists. Hypothesis: Pharmacy medication initiation and titration of HF medications can be implemented successfully at two sites in VA Palo Alto HCS and will increase recommended use of three medication classes for Veterans with HF. Gaps Addressed (Knowledge and Practices). A National HF Dashboard is available to track guideline recommended therapy and shows many patients are not receiving optimal HF car e. Innovation. The use of PACT pharmacists to provide protocolized care for HF will free up primary care providers from this work allowing them to increase access to primary care. Given that patients are often referred to VA Cardiology for this task, pharmacist management can also improve access to VA Cardiology. Specific Aims 1) Implement pharmacist led protocolized care in PACTs for the initiation and titration of HF medications at two types of primary care sites. 2) Determine facilitators, barriers, fidelity and cost of implementation. 3) Demonstrate an impact on recommended HF care and increased access to VA Primary Care and VA Cardiology as a result of PACT pharmacist management. Project Methods We have partnered with pharmacy and PACT leadership at VA Palo Alto HCS in their use of PACT pharmacist HF medication management at one CBOC (Monterey, CA). In this project we will spread this practice to two types of sites: VA Palo Alto Medical Center based Primary Care Clinic (large) and the VA San Jose CBOC, CA (small). Implementation Strategies As part of the proposed project we (partnership of the VISN CMO Dr. Godbout and the QUERI Team) will 1) organize local champions, 2) facilitate spread to the two sites and 3) provide audit and feedback to PACT pharmacy and primary care leadership. We will bring together local champions (VA Pharmacy, VA Primary Care and VA Cardiology leadership) who will be shown results over time and will provide advice on how to modify the implementation for their site. To facilitate implementation, we will develop and provide an operation manual and toolkit that includes pharmacy medication management protocols. Evaluation Our evaluation will examine implementation (e.g. fidelity, barriers, facilitators, cost, provider satisfaction, employee engagement) and outcomes (fraction of patients meeting guideline recommended care, access). Description of primary outcomes/endpoints. The implementation outcomes will include the number of HF patients managed by pharmacists per month per PACT team, and number of medication changes made by PACT pharmacists per month per PACT team. Pharmacist and primary provider satisfaction and perceived burden with the expanded pharmacist role will be determined. Cost of implementation will be determined and compared with benefits (increased access, increased quality of care metrics) to provide both a business case analysis and return on investment. The care outcomes will be use of five VA recommended HF medication classes from the National VA HF Dashboard, access/wait times for PACT and VA Cardiology appointments, admission, readmission, mortality, emergency department visits and adverse drug reactions.

理由。心力衰竭（HF）是VA中的常见疾病，具有高发病率和死亡率。 因此，HF住院和死亡率是VA安全性分析改善和学习的重点 （SAIL）.此外，HF医学治疗是复杂的，因为现在已知有四类药物， 独立延长生存，并建议一起使用（五个非洲裔美国人）。 几种药物需要滴定到推荐剂量，同时监测不常见但危险的 副作用.考虑到治疗的复杂性和心脏病专家的数量不足， 大量的患者人群、标准化的药物开始和非医生的药物滴定， 已被测试为患者对齐护理团队（PACT）当前初级护理实践的辅助工具。药剂师 已经发现药物的开始和滴定可以改善多个患者的推荐护理， 随机试验然而，很少有VA研究中心实施药物启动和药物滴定 由PACT药剂师进行。假设：HF药物的药房用药开始和滴定可以 在VA Palo Alto HCS的两个站点成功实施，并将增加三个站点的推荐使用量 为HF退伍军人提供药物治疗。弥补差距（知识和做法）。国家HF 仪表板可用于跟踪指南推荐的治疗，并显示许多患者未接受 最佳高频车e.创新使用PACT药剂师为HF提供协议化护理将释放 初级保健提供者从这项工作中受益，使他们能够增加获得初级保健的机会。鉴于患者 药剂师管理也可以改善VA的可及性， 心脏科。具体目标1）在PACTs中实施药剂师主导的方案化护理， 在两种类型的初级保健场所滴定HF药物。2)确定促进者、障碍、忠诚度和成本 的执行。3)证明对推荐的HF护理和增加VA初级治疗的影响 护理和VA心脏病学作为PACT药剂师管理的结果。项目方法我们已经合作 与VA Palo Alto HCS的药房和PACT领导层一起使用PACT药剂师HF药物 管理在一个CBOC（蒙特雷，CA）。在这个项目中，我们将把这种做法推广到两种类型的网站： 帕洛阿尔托医疗中心的初级保健诊所（大）和弗吉尼亚州圣何塞CBOC，加利福尼亚州（小）。 实施策略作为拟议项目的一部分，我们（合作伙伴的VISN CMO博士Godbout 和QUERI团队）将1）组织当地冠军，2）促进向两个地点传播，3）提供 审核并反馈给PACT药房和初级保健领导层。我们将把当地的冠军 (VA药房、VA初级保健和VA心脏病学领导层），他们将随着时间的推移显示结果， 提供有关如何修改其站点实现的建议。为方便实施，我们会制定 并提供包括药房药物管理协议的操作手册和工具包。 评估我们的评估将检查实施情况（例如，忠诚度、障碍、促进者、成本、提供者 满意度，员工参与度）和结果（符合指南推荐护理的患者比例， 访问）。描述主要结局/终点。实施成果将包括： 每个PACT团队每月由药剂师管理的HF患者数量和药物数量 每个PACT团队每月由PACT药剂师进行的更改。药剂师和主要提供者满意度 并将确定扩大药剂师角色的感知负担。实施成本将为 确定并与益处（增加的访问，提高的护理指标质量）进行比较，以提供 商业案例分析和投资回报。护理结局将是使用VA推荐的5种HF 国家VA HF仪表板中的药物类别、PACT和VA心脏病学的访问/等待时间 预约、入院、再入院、死亡率、急诊科就诊和药物不良反应。