MEDication Focused Outpatient Care for Underutilization of Secondary Prevention

描述(申请人提供)：心血管疾病(CVD)每天在美国造成2200人死亡，每39秒就有一人死亡。有证据表明，通过更好的风险因素管理，这些死亡是可以预防的，然而，许多风险因素仍然无法控制。以患者为中心的医疗之家(医疗之家)包括自我管理、个性化健康记录和基于团队的护理，已被提出作为缩小护理提供方面的这些差距的一项战略。Cochrane的几篇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遵守。管理保健组织发现，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。目前尚不清楚是否会在典型的办公室做法中实施全面的CVRS模式，这种缺乏证据的情况是文献中的一个主要空白。此应用程序的目标是在地理、种族和民族多样性较大的医疗机构中利用集中式CVRS进行一项多中心、整群随机研究，以确定CVRS模型的实施程度。我们将把16个初级保健办公室随机分配到CVR或常规护理，并招募400名受试者，其中220名受试者将来自少数族裔。我们还将在每个办公室选择25名患者(n=400，总共n=800)进入被动观察组，这将使我们能够确定干预措施对非暴露患者更广泛的传播程度。我们的中心假设是，将实施由临床药剂师管理的集中式CVR，并使用指南优势指标显著改善CVD指南的遵从性。这项拟议研究的基本原理是，实施一项改善心血管疾病二级预防的新战略将导致全美卫生系统更广泛地采用创新战略。我们将实现我们的目标，并用以下具体目标检验我们的中心假设：我们的主要目标是：确定由临床药剂师管理的基于网络的CVR是否将在不同的初级保健办公室实施。我们推测，与对照组相比，从诊所随机进入集中CVRS组的患者对心血管疾病二级预防指南的遵守程度将显著更高。这项研究预计将产生以下结果：指南遵从性在基线时为40%，在干预组12个月时至少增加到60%。我们预计，在干预停止后，指南的遵从性将会恶化，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.