Factors and Outcomes Associated with Inappropriate Prescribing of Phosphodiesterase-5-Inhibitors for Pulmonary Hypertension

与磷酸二酯酶 5 抑制剂不当治疗肺动脉高压相关的因素和结果

• 批准号: 9927919
• 负责人: Renda Soylemez Wiener
• 金额: --
• 依托单位: EDITH NOURSE ROGERS MEMORIAL VETERANS HOSPITAL
• 依托单位国家: 美国
• 财政年份: 2016
• 资助国家: 美国
• 起止时间: 2016-06-01 至 2020-11-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9927919
• 关键词: Acute respiratory failure; Address; Adverse effects; Affect; American; Automobile Driving; Behavior; Caring; Clinical Practice Guideline; Collaborations; Complex; Data; Decision Making; Dose; Echocardiography; Emergency department visit; Equilibrium; Event; Frequencies; Future; Gatekeeping; Goals; Guidelines; Healthcare; Heart Diseases; Heart failure; Hospitalization; Hypoxemia; Iatrogenesis; Internal Medicine; Intervention; Interview; Kidney Failure; Knowledge; Leadership; Learning; Left; Link; Lung diseases; Medical Societies; Medicare; Medicare claim; Medicine; Methods; Modeling; Morbidity - disease rate; Office Management; Outcome; Patient Care; Patients; Pharmaceutical Preparations; Pharmacists; Policies; Private Sector; Process; Protocols documentation; Provider; Pulmonary Hypertension; Pulmonology; Qualitative Evaluations; Recommendation; Risk; Role; Sampling; Shock; Site; Testing; Time; Translating; Trust; Variant; Vasodilator Agents; Veterans; Work; aged; care coordination; cohort; cost; design; effective intervention; empowered; individual patient; informant; inhibitor/antagonist; interest; medical specialties; mortality; outcome prediction; pharmacy benefit; phosphodiesterase V; point of care; prevent; programs; sildenafil; sound

 DESCRIPTION (provided by applicant): Both within and outside the VA, inappropriate use of medications is common, affecting approximately 20-25% of Veterans aged 65 years or older. As such, VHA has shown great interest in the American Board of Internal Medicine's Choosing Wisely campaign, which asks medical societies to identify five commonly used tests or treatments in their specialty that provide little benefit to patients, may cause harm, and are costly. One of the Choosing Wisely recommendations advised against inappropriate use of vasodilators such as phosphodiesterase-5-inhibitors (PDE5I) for certain types of pulmonary hypertension (PH). These medications are costly and can be harmful when used inappropriately. In our pilot work we found that over 4000 Veterans were treated with PDE5I for PH from FY 2005-2012, with 100-fold variation in frequency of inappropriate use across sites. In order to reduce inappropriate prescribing, we must first understand the factors driving decision-making surrounding prescribing of PDE5I for PH, as well as the outcomes associated with its use in VA. This work will identify lessons on how to reduce inappropriate prescribing that can be applied to de-implement use of other high cost medications with little benefit and potential for harm. We propose a mixed methods study with the following 3 specific aims: 1: Identify patient-, clinician-, and site-level determinants of inappropriate use of PDE5I for PH 2: Evaluate processes of prescribing and approval of PDE5I for PH in local contexts and identify best practices 3: Assess the outcomes of inappropriate use of PDE5I for PH. The study aims include: Aim 1: Using national VA data and linked Medicare claims, we will build mixed effects regression models to assess factors associated with inappropriate prescribing of PDE5I for PH, comparing patients prescribed PDE5I with similar patients who did not receive PDE5I. Aim 2: Through protocol review and in- depth qualitative interviews with key informants (patients, clinicians, pharmacists, VA leadership), we will conduct qualitative evaluations of patient-provider and inter-professional processes that result in decisions about use of PDE5I for PH at 6 VA sites (3 with high utilization, 3 with low utilization). Aim 3: We will form cohorts of PH patients who did or did not receive PDE5I inappropriately and identify outcomes using national abstracted data. Risks for important outcomes, including mortality, hospitalizations, and adverse effects of PDE5I, will be compared in the two cohorts. We will perform propensity score matching to adjust for potential confounding. Promoting safe and effective prescribing is a primary goal of the VHA, and of our operational partners in the Pharmacy Benefits Management office and the National Program Office for Pulmonary Medicine. This proposal will lay the groundwork to inform a future proposal to develop and implement targeted strategies to reduce inappropriate prescribing of PDE5I for PH. Moreover, this work will serve as a generalizable test case to inform how several factors influence prescribing: 1) tensions between guidelines, VA policies, and individual patient care, 2) how non-VA prescriptions for dual care patients are handled, 3) role of pharmacists in gate-keeping and point-of-care decision-making, 4) local implementation of national policies. This work is firmly in line with the call to de-implement ineffective care outlined in the Blueprint for Excellence (Strategy 2).

 描述（由申请人提供）： 在VA内外，不适当使用药物是常见的，影响大约20-25%的65岁或以上的退伍军人。因此，VHA对美国内科医学委员会的“明智选择”活动表现出极大的兴趣，该活动要求医学会确定其专业中五种常用的测试或治疗方法，这些测试或治疗方法对患者几乎没有好处，可能会造成伤害，并且成本高昂。其中一项明智选择的建议建议是，对于某些类型的肺动脉高压（PH），不要不适当地使用血管扩张剂，如磷酸二酯酶-5-抑制剂（PDE 5I）。这些药物价格昂贵，使用不当可能有害。在我们的试点工作中，我们发现从2005-2012财年，超过4000名退伍军人接受了PDE 5I治疗PH，不同研究中心的不当使用频率相差100倍。为了减少不适当的处方，我们必须首先了解推动PDE 5I治疗PH处方决策的因素，以及与其在VA中使用相关的结局。这项工作将确定如何减少不适当处方的经验教训，这些经验教训可以应用于取消使用其他高成本药物，这些药物几乎没有好处和潜在的危害。我们提出了一个混合方法研究，具有以下3个具体目标：1：确定患者，临床医生， 和研究中心层面的决定因素不适当使用的PDE 5I PH 2：评价处方和批准的过程PDE 5I PH在当地的情况下，并确定最佳做法3：评估的结果不适当使用的PDE 5I PH。研究目的包括：目的1：使用国家退伍军人事务部数据和相关的医疗保险索赔，我们将建立混合效应回归模型，以评估与不适当处方PDE 5I治疗PH相关的因素，并将处方PDE 5I的患者与未接受PDE 5I的类似患者进行比较。目的2：通过方案审查和对关键知情者（患者，临床医生，药剂师， VA领导），我们将对患者-提供者和跨专业流程进行定性评价，从而决定在6个VA站点（3个利用率高，3个利用率低）使用PDE 5I治疗PH。目标3：我们将形成PH患者的队列， 不适当地接受PDE 5I，并使用国家摘要数据确定结局。将在两个队列中比较重要结局的风险，包括死亡率、住院和PDE 5I的不良反应。我们将进行倾向评分匹配，以调整潜在的混杂因素。促进安全有效的处方是VHA以及我们在药房福利管理办公室和国家肺医学项目办公室的运营合作伙伴的主要目标。该提案将为未来制定和实施有针对性的策略以减少PH患者不适当的PDE 5I处方奠定基础。此外，这项工作将作为一个可推广的测试案例，以告知几个因素如何影响处方：1）指南、VA政策和个体患者护理之间的紧张关系，2）如何处理双重护理患者的非VA处方，3）药剂师在把关和护理点决策中的作用，4）国家政策的地方实施。这项工作与蓝图中概述的取消无效护理的呼吁完全一致， 卓越（战略2）。