Feedback of Treatment Intensification Data to Reduce Cardiovascular Disease Risk

描述(由申请人提供)： 背景：尽管已有高效的药物用于控制主要心血管疾病(CVD)危险因素，但许多患者，包括许多发生CVD的高危患者，对血压(BP)、低密度脂蛋白(LDL-c)和血红蛋白A1c(A1c)的控制仍然很差。最近的证据表明，临床医生未能开出推荐的增加用药方案的建议，往往与对这些结果的不良控制有关。“强化治疗”，即临床医生在控制不佳的情况下适当增加药物治疗的频率，已被提议作为临床质量的新衡量标准。强化治疗等过程措施与临床益处的联系往往得到强有力的临床试验证据的支持。这种措施也可能比风险因素控制报告更有用，因为改进控制所需的行动在措施中是隐含的，而且基本上避免了对病例组合差异的担忧。然而，几乎没有经验证据表明，报告和改进这些流程措施可以带来更好的结果。 项目描述：我们提出了一项整群随机试验干预，涉及北加州凯撒永久医院(KP)的八个或更多医疗机构和超过65,000名心血管疾病高危患者。在干预设施，从KP的电子健康记录中获得的关于需要强化治疗(用于收缩压、低密度脂蛋白和A1c)和最近用药依从性的患者水平信息被添加到人口管理数据库中，并通过与初级保健提供者合作的工作人员目前使用的软件进行反馈。控制设施的工作人员继续使用相同的人口管理数据库和软件，但只收到有关风险因素水平和选定药物的信息。 具体目标： SA1：评估在心血管疾病高危患者中测量和反馈强化治疗信息的有效性，以提高强化治疗的比率和降低控制不佳的SBP、LDL-c和A1c水平。 SA2：与当前做法相比，评估干预对患者总数的影响 接触者、门诊就诊和护理费用与风险因素控制的改善有关。 SA3.评估这一创新对医生和工作人员对高危患者人口管理计划的价值(有效性和效率)的认知的影响。 相关性：如果这项转化性研究表明，强化治疗信息的反馈导致了更高的强化比率和更好的风险因素控制，那么它将证明在人群水平上使用健康信息技术来提高临床质量，并将验证强化治疗作为临床质量的衡量标准。

DESCRIPTION (Provided by the Applicant): Background: Despite the availability of highly effective medications for controlling the major cardiovascular disease (CVD) risk factors, many patients, including many at high risk for developing CVD, continue to be in poor control of blood pressure (BP), LDL-cholesterol (LDL-c), and hemoglobin A1c (A1c). Recent evidence indicates that clinician failure to prescribe recommended increases in the intensity of medication regimens is frequently found in association with poor control of these outcomes. "Treatment intensification," the frequency with which clinicians appropriately increase pharmacotherapy in the face of poor control, has been proposed as a new measure of clinical quality. The linkage of process measures such as treatment intensification to clinical benefit is often supported by strong clinical trial evidence. Such measures could also be more useful than reports of risk factor control because the actions needed to improve control are implicit in the measures and because concerns about case-mix differences are largely avoided. However, there is little empirical evidence that reporting and improving these process measures can lead to better outcomes. Project Description: We propose a cluster randomized trial intervention involving eight or more medical facilities of Kaiser Permanente Northern California (KP) and more than 65,000 patients at high risk for CVD. At intervention facilities, patient-level information obtained from KP's electronic health record on the need for treatment intensification (for systolic BP, LDL-c, and A1c) and on recent medication adherence are added to a population management database and fed back through software currently used by staff working with primary care providers. Staff at control facilities continue to use the same population management database and software but only receive information on risk factor levels and selected medications. Specific Aims: SA1: Evaluate the effectiveness of measurement and feedback of treatment intensification information in patients at high risk of CVD for improving rates of treatment intensification and for reducing levels of poorly controlled SBP, LDL-c, and A1c. SA2: Evaluate the impact of the intervention, compared to current practice, on total numbers of patient contacts, outpatient visits, and costs of care in relation to improvements in risk factor control. SA3. Evaluate the effect of this innovation on physician and staff perceptions of the value (effectiveness and efficiency) of the population management program for high risk patients. Relevance: If this translational study demonstrates that feedback of information on treatment intensification leads to higher rates of intensification and improved risk factor control, it will have demonstrated a population level use of health information technology for improving clinical quality, and will also have validated treatment intensification as a metric of clinical quality.