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.

正当性。心力衰竭是退伍军人中的常见病，发病率高，病死率高。 因此，心衰住院和死亡率是退伍军人事务部安全分析改进和学习的重点 (风帆)。此外，心力衰竭的医疗治疗是复杂的，因为现在已知有四种药物 单独使用可延长存活期，建议联合使用(非洲裔美国人使用五种)。 几种药物需要滴定到推荐剂量，同时监测不常见但危险的药物 副作用。考虑到治疗的复杂性和心脏病医生的数量不足 庞大的患者群体，非内科医生标准化的用药启动和药物滴定 作为患者看护团队(PACT)当前初级护理实践的辅助工具进行了测试。药剂师 药物起始和药物滴定已被发现在多个国家改善推荐护理 随机试验。然而，很少有VA站点实施药物启动和药物滴定 由PACT药剂师治疗心力衰竭。假设：药房的用药启动和HF药物的滴定可以 在退伍军人事务部Palo Alto HCS的两个地点成功实施，并将增加建议的三个 为患有心力衰竭的退伍军人开设的药物课程。解决差距(知识和实践)。一个全国性的高频 仪表板可用于跟踪指南推荐的治疗，并显示许多患者没有接受 最佳高频轿车e.创新。使用PACT药剂师为心力衰竭提供程序化护理将使 这项工作的初级保健提供者使他们能够更多地获得初级保健。考虑到患者是 对于这项任务，药剂师管理通常被称为退伍军人事务部心脏科，也可以改善获得退伍军人管理局的机会 心脏科。具体目标1)在启动和实施协议中实施药剂师领导的程序化护理 在两种类型的初级保健地点滴定HF药物。2)确定促进者、障碍、忠诚度和成本 实施的重要性。3)展示对推荐的心力衰竭护理和增加退伍军人事务部初级保健机会的影响 CARE和VA心脏病学作为PACT药剂师管理的结果。我们合作的项目方法 与VA Palo Alto HCS的药房和PACT领导一起使用PACT药剂师HF药物 一家CBOC(加利福尼亚州蒙特利)的管理层。在这个项目中，我们将把这种做法推广到两种类型的站点： 总部设在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(小)。 实施战略作为拟议项目WE(VISN CMO Dr.Godout的伙伴关系)的一部分 和QUERI团队)将1)组织本地冠军，2)促进向两个网站的传播，3)提供 审核并反馈给药房和初级保健领导层。我们将汇聚当地的冠军企业 (退伍军人管理局药房、退伍军人初级保健和退伍军人心脏病领导力)谁将随着时间的推移而展示结果，并将 就如何修改其站点的实现提供建议。为了促进实施，我们将制定 并提供包括药房用药管理规程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、提供商 满意度、员工敬业度)和结果(满足指南建议的护理的患者比例， 访问)。对主要结果/终点的描述。实施成果将包括 每个PACT团队每月由药剂师管理的心衰患者数量和用药数量 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的满意度 并将确定扩大药剂师角色所带来的感知负担。实施成本将为 确定并与优势(更多的访问机会、更高的护理质量指标)进行比较，以提供 商业案例分析和投资回报。护理结果将使用五个VA推荐的HF 国家退伍军人管理局HF仪表板上的药物课程、PACT和退伍军人心脏病学的访问/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。