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

摘要

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.