Reducing Polypharmacy and Fall Risk for Multi-Morbid Adults with Chronic Obstructive Pulmonary Disease

项目总结 慢性阻塞性肺疾病(COPD)是美国发病率和死亡率的主要原因 导致生活质量和功能状态显著下降。慢性阻塞性肺疾病患者的发病率是 比没有COPD的患者更有可能跌倒，使这些患者处于与跌倒相关的伤害的高风险中，并进一步 生活质量和健康水平下降。这项研究将解决使用Fall的常见而重要的问题- COPD患者的风险增加药物(FRID)。这将通过实施和 评估药剂师领导的停药干预措施，以减少社区住宅、多个社区的FRID使用 患有慢性阻塞性肺疾病的病态成年人。这项提议的中心假设是沟通不畅和有限 处方者、患者和患者护理人员之间的共同决策代表着可修改的障碍 停药。一旦这些障碍被解决，处方医生、患者和护理人员将服从于 知情停药是这项有针对性干预的一部分。在具体目标1中，我将利用一个国家数据库 评估COPD患者常用的FRID，确定FRID的类型和组合 与最高的跌倒风险有关。在具体目标2中，我将采访COPD患者及其家人 护理者和临床医生(初级保健提供者、肺科医生、药剂师)以引出障碍、促进者 以及取消FRID处方并加强临床医生和 病人。在具体目标3中，我将进行一项试点随机试验，测试药剂师主导的停药 干预，根据具体目标1和2的调查结果进行调整。我将评估其可行性、可接受性和 采用半结构化访谈和结构化问卷对干预措施的适宜性进行研究。我也会 探讨干预组与常规护理组对干燥症主要结局的初步疗效 停产。这项试点试验将为未来R01资助的混合动力有效性提供初步数据- 实施试行。这项研究的创新之处在于：1)以前没有研究评估过干预措施 促进慢性阻塞性肺疾病患者停用FRID；2)这种干预包括家庭照顾者，他们 为患者提供非正式的用药管理；以及3)该项目使用以肺部诊所为基础的 药剂师作为改善患者、照顾者之间沟通和共享决策的渠道 和临床医生。我的学习目标是学习a)先进的统计方法来评估跌倒的风险 COPD患者，b)COPD治疗培训和跌倒风险评估，c)行为干预 优化、适应和评估，以及d)未来干预试验的行为临床试验设计。 我的长期职业目标是评估和传播循证干预措施，以改善 为患有多种疾病的成人慢性阻塞性肺疾病患者提供药物管理和保健服务。

Project summary Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality in the US and results in significant reduction in quality of life and functional status. Patients with COPD are 55 times more likely to fall than patients without COPD, putting these patients at high risk of fall-related injuries and further decrements in quality of life and health. This study will tackle the common and important problem of use of fall- risk increasing drugs (FRIDs) among patients with COPD. This will be achieved by implementing and evaluating a pharmacist-led deprescribing intervention to reduce FRIDs use among community-dwelling, multi- morbid adults with COPD. The central hypothesis of this proposal is that poor communication and limited shared decision making between prescribers, patients, and patient caregivers represent modifiable barriers to deprescribing. Once these barriers are addressed, prescribers, patients and caregivers will be amenable to informed deprescribing as part of this targeted intervention. In Specific Aim 1, I will use a national database to assess commonly used FRIDs among patients with COPD, identifying FRID types and combinations associated with the highest fall risk. In Specific Aim 2, I will interview patients with COPD, their family caregivers, and clinicians (primary care providers, pulmonologists, pharmacists) to elicit barriers, facilitators and key strategies to deprescribing FRIDs and enhancing shared decision making between clinicians and patients. In Specific Aim 3, I will conduct a pilot randomized trial, testing a pharmacist-led deprescribing intervention, adapted using findings from Specific Aims 1 and 2. I will evaluate the feasibility, acceptability and appropriateness of the intervention using semi-structured interviews and structured questionnaires. I will also explore the preliminary efficacy of the intervention compared to usual care for the primary outcome of FRID discontinuation. This pilot trial will provide preliminary data for a future R01-funded hybrid effectiveness- implementation trial. This research is innovative in that: 1) no prior study has evaluated an intervention to facilitate deprescribing FRIDs among patients with COPD; 2) this intervention includes family caregivers, who provide informal medication management to patients; and 3) this project uses a pulmonary clinic-based pharmacist as a conduit to improve communication and shared decision making among patients, caregivers and clinicians. My learning objectives are to learn a) advanced statistical methods to evaluate fall risk among patients with COPD, b) training on COPD therapeutics and fall risk assessment, c) behavioral intervention optimization, adaptation and assessment, and d) behavioral clinical trials design for future intervention trials. My long-term career goals are to evaluate and disseminate evidence-based interventions to improve medication management and healthcare delivery for multi-morbid adults with COPD.