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

摘要 随着人类免疫缺陷病毒(HIV)感染者年龄的增长，慢性阻塞性肺疾病(COPD)是最常见的 流行的共病。令艾滋病毒感染患者担忧的是，慢性阻塞性肺疾病给患者带来了实质性的 发病率高，并与死亡率增加有关。然而，慢性阻塞性肺疾病被低估了，而且往往不适当。 在艾滋病毒患者中管理，可能会加剧与慢性阻塞性肺病相关的发病率。优化管理 慢性阻塞性肺病的治疗包括改善对推荐做法的吸收和停止无效和有害的做法。 COPD的准确诊断可以确定哪些人将受益，哪些人不会受益 慢性阻塞性肺病治疗。适当使用长效吸入器控制COPD改善症状，与健康相关 生活质量、功能状态和降低病情恶化的风险。停止使用不适当的吸入器- 特别是吸入皮质类固醇--可以最大限度地减少副作用的危害，这些副作用可能是特别严重的 在艾滋病毒患者中，考虑到他们伴随的免疫妥协、多病和多药联用。我们建议 测试优化COPD护理的干预措施，以促进有效的、循证的护理和取消实施 艾滋病患者慢性阻塞性肺疾病的不适当治疗。我们是一个由关键利益相关者组成的多学科团队 具有慢性阻塞性肺病、艾滋病毒和实施科学专业知识的调查人员，具有研究类似 干预措施。这种干预以慢性护理模式为基础，促进了初级保健的专家支持 护理，包括作为艾滋病毒初级保健提供者的传染病(ID)医生 身份证诊所的病人。而不是依赖转介驱动的专科护理，这可能是获得的障碍， 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群体 慢性阻塞性肺病，提供针对个别艾滋病毒患者的实时循证建议。我们会 利用退伍军人事务部(VA)临床和信息学基础设施进行沟通 制定建议的团队成员和患者的临床提供者之间通过 电子健康记录作为一种主动的(即由肺部发起的)电子咨询。抵消ID的潜在增长 对于提供商的工作量，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，保留自主权。我们将使用改装的阶梯形楔子 干预设计，使用RE-AIM(REACH、有效性、采用、 实施和维护)框架。我们将评估最佳COPD护理的障碍和促进者 对于艾滋病毒患者，以及有效采用、实施和维持积极主动的电子咨询 方案，以实施研究综合框架为指导。这种干预可以增强 可持续地将被证明有效的干预措施纳入艾滋病毒患者的常规临床实践，他们是 面临慢性阻塞性肺病护理方面的差异和慢性阻塞性肺病造成的不良健康后果的风险。

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.