eAlign: A Patient Portal-based Intervention to Align Medications with What Matters Most

项目摘要 患有阿尔茨海默病和相关痴呆症（ADRD）的老年人经常服用多种药物， 潜在不适当的药物（PIM），使他们处于药物不良事件的风险增加，药物 相互作用、治疗负担和死亡率。减少或停止使用有害药物 或不太可能有益）可以改善痴呆症患者（PLWD）的预后。总体 该提案的目标是完善和试点干预措施，其中ADRD护理合作伙伴在初级 护理，并通过患者门户网站提供教育材料，让他们取消处方， PLWD。我们提出了一种多组件干预措施eAlign，其中包括：1）便利的患者门户 PLWD和护理伙伴的登记;以及2）提供患者门户介入以调整药物治疗 决定与PLWD和护理伙伴的目标，提供护理伙伴的非药物治疗培训， 行为和心理症状的痴呆症，并减少多药和PIM的使用。我们建议 以下具体目标：在目标1中，我们从两个方面描述了关于药物使用的三元相互作用 互补的观点。在目标1a中，我们评估了 PLWD和护理伙伴在与临床医生协商期间影响取消处方建议的采纳 药师我们定性分析了120次录音访问的内容， 在初级保健中，药剂师领导的对PLWD及其护理伙伴的取消处方干预。在目标1b中， 识别影响患者使用的个体（PLWD）和背景（卫生系统、诊所、临床医生）因素 通过检查患者门户网站的摄取和使用，在PLWD中进行药物管理的门户网站， 以及在两个卫生系统中接受初级保健的n= 7，500名PLWD的时间戳电子交互。在 目标2，我们通过以用户为中心的设计过程迭代地改进eAlign协议， 与关键利益相关者的访谈（n=15-20对患者护理合作伙伴和10-15名一线工作人员，临床医生， 临床信息学家和卫生系统领导人）。在目标3中，我们将试验 两个医疗保健系统共有100个患者护理合作伙伴对， 可行性，可接受性和初步疗效为未来的多地点集群随机试验。我们将进行 两组试点随机试验，以检查测量两个主要结局的可行性（ 慢性每日药物和PIM处方率（PLWD）和一名患者报告的继发性 结果，家庭照顾者药物管理麻烦量表。这项工作将建立 初步的数据，方法和合作伙伴关系，以进行多地点嵌入式实用的临床试验， 基于三元组的行为干预，以促进患者和护理伙伴的参与， 与患者的价值观，并促进改善健康和福祉的结果，为PLWD及其护理伙伴。

PROJECT SUMMARY Older adults with Alzheimer’s disease and related dementias (ADRD) often take multiple medications and use potentially inappropriate medications (PIM), placing them at increased risk of adverse drug events, drug interactions, treatment burden, and mortality. Deprescribing (reducing or stopping medications that are harmful or unlikely to be beneficial) can improve outcomes for people living with dementia (PLWD). The overarching goal of this proposal is to refine and pilot an intervention in which ADRD care partners are identified in primary care and provided with educational materials through the patient portal to engage them in deprescribing for PLWD. We propose a multicomponent intervention, eAlign, which includes: 1) Facilitated patient portal registration for both PLWD and care partners; and 2) delivery of a patient portal intervention to align medication decisions with PLWD and care partners goals, provide care partner training in nonpharmacologic treatment of behavioral and psychological symptoms of dementia, and reduce polypharmacy and PIM use. We propose the following specific aims: In Aim 1, we characterize triadic interactions regarding medication use from two complementary perspectives. In Aim 1a we assess how communication dynamics and characteristics of PLWD and care partners affect uptake of deprescribing recommendations during consultation with a clinical pharmacist. We qualitatively analyze content of 120 audiorecorded visits conducted as part of an ongoing, pharmacist-led deprescribing intervention for PLWD and their care partners in primary care. In Aim 1b we identify individual (PLWD) and contextual (health system, clinic, clinician) factors that affect use of the patient portal for medication management among PLWD by examining uptake and use of the patient portal from date and time-stamped electronic interactions of n=7,500 PLWD receiving primary care in two health systems. In Aim 2, we iteratively refine the eAlign protocol through a user-centered design process involving in-depth interviews with key stakeholders (n=15-20 patient-care partner dyads and 10-15 frontline staff, clinicians, clinical informaticists and health system leaders) at both health care systems. In Aim 3, we will pilot the resultant eAlign protocol with a total of 100 patient-care partner dyads at both health care systems to establish feasibility, acceptability and preliminary efficacy for a future multisite cluster randomized trial. We will conduct a two-group pilot randomized trial to examine feasibility of measuring two primary outcomes (total number of chronic daily medications and rates of PIM prescriptions among PLWD) and one caregiver-reported secondary outcome, the Family Caregiver Medication Administration Hassles Scale. This work will establish the preliminary data, methods, and partnerships to undertake a multisite embedded pragmatic clinical trial of a triadic-based behavioral intervention to promote patient and care partner engagement, foster care that aligns with patients’ values, and promote improved health and well-being outcomes for PLWD and their care partners.