Feedback of Treatment Intensification Data to Reduce Cardiovascular Disease Risk

描述（申请人提供）： 背景资料：尽管有高度有效的药物可用于控制主要心血管疾病（CVD）风险因素，但许多患者（包括许多CVD高风险患者）的血压（BP）、LDL-胆固醇（LDL-c）和血红蛋白A1 c（A1 c）仍然控制不佳。最近的证据表明，临床医生未能处方建议增加强度的药物治疗方案，经常发现与这些结果的控制不良。“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，已被提出作为临床质量的新措施。强化治疗等过程措施与临床获益之间的联系通常得到强有力的临床试验证据的支持。这些措施也可能比关于风险因素控制的报告更有用，因为改进控制所需的行动隐含在这些措施中，而且基本上避免了对病例组合差异的关切。然而，几乎没有经验证据表明，报告和改进这些过程措施可以带来更好的结果。 项目描述：我们提出了一个集群随机试验干预，涉及八个或更多的医疗设施的凯撒永久北方加州（KP）和超过65,000例高风险的心血管疾病患者。在干预机构，从KP的电子健康记录中获得的关于治疗强化需求（收缩压，LDL-c和A1 c）和最近药物依从性的患者信息被添加到人口管理数据库中，并通过目前与初级保健提供者合作的工作人员使用的软件反馈。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，但只收到关于风险因素水平和选定药物的信息。 具体目标： SA1：评价CVD高风险患者治疗强化信息的测量和反馈对提高治疗强化率和降低控制不良的SBP、LDL-c和A1 c水平的有效性。 SA 2：与当前实践相比，评价干预对患者总数的影响 接触，门诊就诊和护理费用与风险因素控制的改善有关。 SA 3.评价这一创新对医生和工作人员对高危患者人群管理计划价值（有效性和效率）的看法的影响。 相关性：如果这项转化研究表明，关于强化治疗的信息反馈可提高强化治疗率并改善风险因素控制，则将证明在人群水平上使用卫生信息技术改善临床质量，并将验证强化治疗作为临床质量的一个指标。

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.