Group Medical Visits in Heart Failure for Post-Hospitalization Follow-Up

 描述(由申请人提供)： 该研究项目的主要目标是通过对患者的教育、疾病监测和通过共享医疗预约(SMA)进行药物滴定来改善心力衰竭(HF)出院患者的健康状况，减少住院和死亡。研究发现，患者在HF中的自我护理行为(例如，药物/饮食不合规)和卫生系统因素(例如，护理不协调、获得机会有限、缺乏对患者和照顾者的教育)对患者的健康状况和住院风险起着重要作用，以至于50%的再次住院被判断为可能/可能可以预防。为了解决基于慢性护理模式的患者和系统因素，通过SMA重新设计护理服务可以是一个很好的解决方案，在提供患者自我管理支持的同时，还可以在同行支持的环境中执行疾病监测和药物管理。我们提出了一项随机对照试验，招募出院后6周内的患者，随机让他们每隔一周接受一次SMA干预，为期8周，而不是常规治疗。我们将在180天后确定，与接受常规护理的患者相比，参加HF-SMA的心力衰竭患者是否：1)体验到由堪萨斯城心肌病问卷(主要结果)和总体健康状况(EQ5D，次要结果)衡量的更好的心脏健康状况；2)住院或死亡减少，3)中间结果改善：a)HF自我护理行为增加，以及b)血浆BNP水平降低。对于接受HF-SMA的患者，我们还将通过进行(A)与患者的面对面访谈和(B)与利益相关者(患者的医生和管理人员)的电话访谈来确定感知的益处、需要改进的领域、实施的潜在障碍以及跨地点干预的忠诚度。这些地点将是弗吉尼亚州普罗维登斯和弗吉尼亚州凤凰城的医院，总共招收375名患者。从随机时间开始，所有患者的研究持续时间为180天。我们将使用分层(参加其他计划的心力衰竭护理，住院时间为6个月，左心室射血分数为40%)，每个站点的区组大小为4的随机区组，以确保分层变量的平衡。该团队将由一名营养师、护士、健康心理学家和临床药剂师或护士实践者组成，没有内科医生在场(心脏病专家将随叫随到)。会议将从评估患者的需求开始，然后是预先指定的以主题为基础的疾病自我管理教育，然后是患者发起的疾病管理讨论，最后是个性化用药病例管理的分组会议。我们的研究结果将被用于医疗管理和系统重新设计，为我们的心衰退伍军人提供更好的质量和以患者为中心的护理。长期目标是在小组环境中使用多学科团队方法在同行支持环境中管理HF支持定期医生访问，所有这些都是提供以患者为中心的护理和改善结果所必需的。

 DESCRIPTION (provided by applicant): The primary goal of this research project is to improve the health status and decrease hospitalization and death for patients discharged with heart failure (HF) via education to patients, disease monitoring and medication titration through shared medical appointments (SMAs). Studies have found patient self-care behaviors in HF (e.g. medication/dietary noncompliance) and health system factors (e.g. care discoordination, limited access, lack of education to patients and caregivers) played an important role in patient's health status and hospitalization risk to the extent that 50% of the readmissions were judged to be possibly/probably preventable. To address patient and system factors based on the Chronic Care Model, redesign of care delivery, via SMA's, can be a good solution to provide patient self- management support while also performing disease monitoring and medication management in an environment of peer support. We propose a randomized controlled trial to enroll patients within 6 weeks of discharge from a HF hospitalization and randomized them to receive either SMA intervention every other week for 8 weeks versus usual care for HF. We will determine, at 180 days from randomization, whether HF patients who participate in HF-SMA, as compared to patients who receive usual care: 1) Experience better cardiac health status measured by Kansas City Cardiomyopathy Questionnaire (primary outcome), and overall health status (EQ5D, secondary outcome); 2) Have fewer hospitalization or death and 3) Experience improvement in intermediate outcomes: a) increase in HF Self-Care behavior, and b) decrease in plasma BNP levels. For patients who underwent HF-SMA, we will also determine perceived benefits, areas in need of improvement, potential obstacles of implementation, and fidelity of the intervention across sites, by conducting (a) face-to-face interviews with patients and (b) telephone interviews with stakeholders (physicians of the patients and administrators). The sites will be Providence VA and Phoenix VA hospitals to enroll a total of 375 patients. The study duration will be 180 days for all patients from the time of randomization. We will use stratified (enrollment in other programs for HF care, <2 hospitalizations last 6 months, left ventricular ejection fraction <40%), block randomization with block sizes of 4 in each site to ensure balance of the stratified variables. The team will consist of a nutritionist, nurse, health psychologist an a clinical pharmacist or nurse practitioner, without the presence of a physician (cardiologist will b available on call). The session will start with an assessment of patient needs followed by pre-assigned theme-based disease self-management education, followed by patient-initiated disease management discussion, and conclude with break-out sessions of individualized medication case management. Our study findings will be used in health care management and system redesign to provide better quality and patient centered care for our veterans with HF. The long-term goal is to use a multi-disciplinary team approach in a group setting to manage HF support regular physician visits, in a peer support environment, all of which, are necessary to provide patient- centered care and improve outcomes.