AdvanCing High quality COPD care for people with immune dysfunction by implementing Evidence-based management through proactive E-consults (ACHIEVE)

摘要 随着艾滋病毒感染（HIV+）患者年龄的增长，慢性阻塞性肺疾病（COPD）是最常见的疾病之一。 常见的共病。在HIV感染患者中令人担忧的是， 发病率和死亡率增加有关。然而，慢性阻塞性肺病的诊断不足，往往是不适当的 在HIV+患者中进行管理，可能会恶化与COPD相关的发病率。优化管理 COPD的治疗包括提高推荐的治疗方法的使用率和停止无效和有害的治疗方法。 COPD的准确诊断可以确定哪些人将受益于-哪些人不会受益- COPD治疗适当使用长效吸入器控制COPD改善症状，健康相关 生活质量、功能状态，并降低急性加重的风险。停用不适当的吸入器- 特别是吸入性皮质类固醇-可以最大限度地减少副作用的危害， 在HIV+患者中，考虑到其伴随的免疫功能低下、多药耐药和多种药物。我们提出 测试一种干预措施，以优化COPD护理，促进有效的循证护理， HIV+患者中COPD的不适当治疗。我们是一个由关键利益相关者组成的多学科团队， 具有COPD、HIV和实施科学专业知识的研究者，具有类似研究经验 干预措施。这种干预措施以慢性病护理模式为基础， 护理，其中包括传染病（ID）医生，他们作为艾滋病毒+的初级保健提供者 ID诊所的病人而不是依赖于家庭驱动的专业护理，这可能是一个障碍， 我们将让肺科医生积极支持艾滋病毒提供者管理艾滋病毒+患者人群， COPD，提供针对HIV+患者个体的实时循证建议。我们将 利用退伍军人事务部（VA）临床和信息学基础设施进行通信 在制定建议的团队成员和患者的临床提供者之间， 电子健康记录作为主动（即，肺源性）电子会诊。为了抵消ID的潜在增加， 提供商的工作量，我们将起草建议作为初步命令，供提供商审查和认可 （签署），修改或取消他们的自由裁量权，保留自主权。我们将使用改进的阶梯楔 干预设计，使用RE-AIM（到达，有效性，采用， 实施和维护）框架。我们将评估最佳COPD护理的障碍和促进因素 为艾滋病毒阳性患者提供服务，并有效采用、实施和维持主动的电子咨询服务， 该计划由实施研究综合框架指导。这种干预可以提高 将经证明有效的干预措施可持续地纳入艾滋病毒阳性患者的常规临床实践， 存在COPD护理差异和COPD不良健康结局的风险。

Abstract As HIV-infected (HIV+) patients age, chronic obstructive pulmonary disease (COPD) is one of the most prevalent comorbid diseases. Of concern among patients with HIV infection, COPD confers substantial morbidity and is associated with increased mortality. Yet, COPD is underdiagnosed and often inappropriately managed in HIV+ patients, likely worsening the morbidity associated with COPD. Optimizing the management of COPD includes improving uptake of recommended and discontinuation of ineffective and harmful practices. Accurate diagnosis of COPD can identify individuals who will benefit – and those who will not benefit – from COPD therapies. Appropriate use of long-acting inhalers to control COPD improves symptoms, health-related quality of life, functional status, and decrease risk for exacerbations. Discontinuation of inappropriate inhalers – particularly inhaled corticosteroids – can minimize harms from side effects that may be particularly problematic in HIV+ persons, given their concomitant immuno-compromise, multimorbidity, and polypharmacy. We propose to test an intervention to optimize COPD care that promotes effective, evidence-based care and de-implements inappropriate therapies for COPD in HIV+ patients. We are a multidisciplinary team of key stakeholders and investigators with expertise in COPD, HIV and implementation science, with prior experience studying similar interventions. The intervention, grounded in the chronic care model, facilitates specialist support of primary care, which includes infectious disease (ID) physicians who serve as the primary care providers for their HIV+ patients in the ID clinic. Rather than relying on referral-driven specialty care, which may be a barrier to access, we will have pulmonologists proactively support HIV providers to manage a population of HIV+ patients with COPD, delivering real-time evidence-based recommendations tailored to the individual HIV+ patient. We will leverage the Department of Veterans Affairs (VA) clinical and informatics infrastructures to communicate between team members developing the recommendations and patients' clinical providers through the electronic health record as a proactive (i.e., pulmonary-initiated) E-consult. To offset potential increases in ID providers' workload, we will draft recommendations as preliminary orders for providers to review and endorse (sign), modify or cancel at their discretion, preserving autonomy. We will use a modified stepped-wedge intervention design, with outcomes evaluated using the RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance) framework. We will evaluate barriers and facilitators of optimal COPD care for HIV+ patients, and of effective adoption, implementation and maintenance of a proactive E-consult program, guided by the Consolidated Framework for Implementation Research. This intervention can enhance the sustainable uptake of proven-effective interventions into routine clinical practice for HIV+ patients, who are at risk of disparities in COPD care and poor health outcomes from COPD.