MEDication Focused Outpatient Care for Underutilization of Secondary Prevention

心血管疾病（CVD）每天在美国造成2，200人死亡，每39秒就有一人死亡。有证据表明，这些死亡是可以通过更好的风险因素管理来预防的，但是，许多风险因素仍然不受控制。以病人为中心的医疗之家（医疗之家），其中包括自我管理，个性化的健康记录和团队为基础的护理，已被提出作为一项战略，以减少这些差距，在提供护理。几项科克伦综述和荟萃分析发现，有证据表明，在初级保健团队中增加药剂师可以改善风险因素控制和医生对指南的依从性。管理式医疗组织发现，由药剂师管理的集中式心血管风险服务（CVRS）可以降低死亡率。目前尚不清楚综合CVRS模型是否会在典型的办公室实践中实施，缺乏证据是文献中的一个主要空白。 本申请的目的是在具有较大地理、人种和种族多样性的医疗机构中利用集中式CVRS进行多中心、随机分组研究，以确定CVRS模型的实施程度。我们将16个初级保健办公室随机分配至CVRS或常规治疗，并入组400例受试者，其中220例受试者来自少数民族。我们还将每个办公室选择25例患者（n=400，总计n=800）进入被动观察组，这将使我们能够确定干预扩散到未暴露患者的更广泛程度。我们的中心假设是，将实施由临床药师管理的集中式CVRS，并使用指南优势指标显著改善CVD指南依从性。这项拟议研究的基本原理是，实施一项新的战略，以改善心血管疾病的二级预防将导致创新的战略，更广泛地采用卫生系统在整个美国。我们将实现我们的目标，并测试我们的中心假设与以下具体目标：我们的主要目标是：以确定是否基于网络的CVRS管理的临床药师将在不同的初级保健办公室实施。我们假设，与对照组相比，随机分配至中心CVRS组的诊所患者对CVD二级预防指南的依从性显著更高。 本研究预计将产生以下结果：基线时指南依从性为40%，12个月时干预组依从性至少增加至60%。我们预计，在干预停止后，指南依从性将恶化，但仍将显著高于对照组。

DESCRIPTION (provided by applicant): Cardiovascular disease (CVD) causes 2,200 deaths in Americans every day with one death every 39 seconds. There is evidence that these deaths can be prevented with better risk factor management, however, many risk factors remain uncontrolled. The Patient-Centered Medical Home (Medical Home) which includes self-management, personalized health records and team-based care, has been proposed as a strategy to reduce these gaps in care delivery. Several Cochrane reviews and meta-analyses have found evidence that adding pharmacists to the primary care team improves risk factor control and physician adherence to guidelines. Managed care organizations have found that a centralized cardiovascular risk service (CVRS) managed by pharmacists can reduce mortality. It is not known if a comprehensive CVRS model would be implemented in typical office practices and this lack of evidence is a major gap in the literature. The objective of this application is t conduct a multi-center, cluster-randomized study utilizing a centralized CVRS in medical offices with large geographic, racial and ethnic diversity to determine the extent to which the CVRS model will be implemented. We will randomize 16 primary care offices to the CVRS or usual care and enroll 400 subjects of which 220 subjects will be from racial minorities. We will also select 25 patients per office (n=400, total n=800) into a passive observation group which will allow us to determine the extent to which the intervention diffuses more broadly for unexposed patients. Our central hypothesis is that a centralized CVRS managed by clinical pharmacists will be implemented and significantly improve CVD guideline adherence using the Guideline Advantage metrics. The rationale for this proposed study is that implementation of a novel strategy to improve secondary prevention of CVD will lead to innovative strategies for broader adoption by health systems throughout the US. We will accomplish our objectives and test our central hypothesis with the following specific aims: Our primary Aim is: To determine if a web-based CVRS managed by clinical pharmacists will be implemented within diverse primary care offices. We postulate that adherence to guidelines for secondary prevention of CVD will be significantly greater in patients from clinics randomized to the centralized CVRS group compared to the control group. This study is expected to produce the following outcomes: guideline adherence will be 40% at baseline and increase to at least 60% in the intervention group at 12 months. We expect guideline adherence will deteriorate after the intervention is discontinued but will remain significantly higher than the control group.