Dissemination of CVD risk factor treatment among diabetic patients in FQHCs

描述（由申请人提供）：我们提出了一个示范和传播项目，将一项降低心血管疾病风险的计划扩展到波特兰大都会地区11个联邦合格健康中心（FQHC）诊所接受糖尿病治疗的弱势门诊人群，该计划已被证明对综合HMO人群中的糖尿病患者（DM）有效。患有糖尿病和其他危险因素的成年人服用阿司匹林、他汀类药物和ACE抑制剂可将心血管事件的风险降低多达40%；拟议的研究将采用Kaiser Permanente使用的干预策略，以增加研究诊所中糖尿病患者使用这些药物的百分比。干预策略源自慢性护理模式，包括基于初级保健团队的护理、主动病例管理、内置在社区诊所通用的电子病历（EMR）中的临床提示、将药房数据集与EMR联系起来以监测患者依从性，以及一个小组报告工具，该工具优先对风险最大的患者进行临床随访。我们将确定干预传播的有效性及其对患者依从性的影响，通过测量糖尿病人群对目标药物的处方率的变化和处方补充率的变化，使用诊所内的前后比较和跨诊所的交错随机实施。我们还将进行进程评价，以确定对传播和实施成功至关重要的因素。我们的首要目标是确定并解决将一个成功的项目从一个大型的、组织良好的卫生系统传播到社区诊所的问题，以便该项目可以在其他拥有适度电子病历基础设施资源的社区卫生中心和实践环境中更广泛地实施。这项建议的研究将为未来利用安全网诊所的电子病历传播循证护理的研究铺平道路。

DESCRIPTION (provided by applicant): We propose a demonstration and dissemination project that extends a cardiovascular disease risk-reduction program shown to be effective among patients with Diabetes Mellitus (DM) in an integrated HMO population, to a vulnerable outpatient population receiving DM care in 11 Federally Qualified Health Center (FQHC) clinics in the Portland, OR metropolitan area. Adults with DM and other risk factors who take aspirin, statins, and ACE Inhibitors can reduce their risk of cardiovascular events by as much as 40%; the proposed study will adapt intervention strategies used by Kaiser Permanente to increase the percentage of DM patients on these medications in the study clinics. Intervention strategies derive from the Chronic Care Model and include primary-care-team-based care, active case management, clinical prompts built into the electronic medical record (EMR) common to the community clinics, linked pharmacy datasets with the EMR to monitor patient adherence, and a panel reporting tool that prioritizes clinical follow-up to those most at risk. We will determine the effectiveness of the dissemination of the intervention, and its impact on patient adherence, by measuring changes in DM population prescription rates for the target medications and changes in prescription refill rates, using a pre- post comparison within clinics and a staggered, randomized implementation across clinics. We will also conduct a process evaluation to identify the factors important to dissemination and implementation success. Our overarching goals are to identify and resolve issues in disseminating a successful program from a large, well-organized health system into community clinics, so that the program may be implemented more widely in other community health centers and practice settings with modest EMR infrastructure resources. The proposed study will pave the way for future research on disseminating evidence-based care using safety net clinics' EMR. PUBLIC HEALTH RELEVANCE: Adults with diabetes who take aspirin, statins, and ACE Inhibitors can dramatically reduce their risk of cardiovascular events. Therefore, five years ago Kaiser Permanente (KP) launched an initiative to put as many of its members with diabetes as possible on this drug regimen, using the electronic medical record to identify patients not taking the medications, and to remind clinicians to start these patients on the medications; in addition, primary care case management teams contacted eligible patients. We propose to implement a similar program in eleven of Oregon's community health centers, to assess whether KP's program can be successfully disseminated in those settings, and whether it can impact the percentage of eligible patients who are prescribed and refill the target medications.