Engaging Patients to Promote Deprescribing

背景-尽管有多个提供商和系统级别的干预，以减少潜在的不适当 药物(PIM)，许多退伍军人仍然是几乎没有好处的处方药，使他们处于 不必要的药物不良事件风险(ADE)。减少产后抑郁的一种机制是停药，一种 以取消实施为基础的方法，深思熟虑地停止患者目前开出的药物。 许多人明智地选择了解决PIM问题的建议。具体地说，质子泵抑制剂(PPI)， 用来降低胃酸的药物，应降至缓解所需的最低剂量。 许多老年糖尿病患者控制过度，血糖水平低于推荐值，但 继续服用多种糖尿病药物，或许能够使用更少的药物。这些患者还在 胰岛素和磺脲类药物引起低血糖的风险较高，应限制这些药物的使用。 最后，加巴喷丁经常被用于非标签治疗疼痛，在过去的几年里大大增加了使用。 取消对PIM的处方存在许多障碍。许多干预措施只针对处方提供者。 尽管一些人认为提供者对停药负有主要责任，但患者开始 停药谈话可以有效地促进停药。在一项单一地点的试点研究中，我们 通过向退伍军人提供以退伍军人为中心的初级护理患者，成功地减少了PIM 授权(“通过患者对最终结果的所有权来消除药物使用”)手册。然而，它是 不知道这种方法对患有其他慢性病的退伍军人或在非试点地点是否同样成功。 目标--我们提出三个目标。1)检查以患者为中心的干预对更换提供者的影响 开处方(主要结果)，由用药的频率决定 停药或降级。2)检查以患者为中心的干预对患者参与的影响； 通过走访后调查退伍军人与宣传册的互动及其对停药的影响 讨论和停药。3)使用定性方法，确定关键的组织背景因素 与支持未来实施的干预措施的保真度、可行性、可接受性和适当性有关。 方法和创新-我们提出了一种使用混合I型的多点准实验试验 有效性--直接向退伍军人提供授权手册的实施设计 取消三组PIM(PPI、糖尿病药物和加巴喷丁)的候选药物的处方。我们会邮寄 与其他研究中使用的分发方法不同，在预定的初级保健访问之前分发小册子。我们的 主要结果将是取消处方和降低目标药物的升级的组合，在 公司数据仓库药房配药记录(目标1)。邮寄调查后寄出 预定的初级保健访问将评估患者对手册的参与度及其对患者的影响- 供应商沟通(目标2)。最后，来自临床医生和工作人员的定性数据解决Proctor的 执行成果将为今后的执行战略(目标3)奠定基础。 意义和下一步-我们的研究直接涉及包括健康在内的多个退伍军人护理优先事项 护理价值、初级保健实践、质量/安全和整体健康，并与当前的退伍军人管理局计划保持一致，以 通过个性化、主动的护理计划确定患者偏好的优先顺序。拟议中的工作是强有力的 药房福利管理和以病人为中心的关怀和文化办公室的支持 改造，这将促进传播研究结果，以提高产品的质量和安全 退伍军人事务部内的用药情况。到研究结束时，我们将建立一个创新、低技术、 以患者为中心的干预措施，促进三个人群常用药物的停药， 从而直接提高VA护理的质量、安全性和价值，同时也为更广泛的 这一方法的实施和推广到其他可能不合适的药物。

Background – Despite multiple provider- and system-level interventions to reduce potentially inappropriate medications (PIMs), many Veterans are still prescribed drugs that provide little benefit, placing them at unnecessary risk of adverse drug events (ADEs). One mechanism to reduce PIMs is through deprescribing, a de-implementation-based approach to thoughtfully discontinue a medication a patient is currently prescribed. Many Choosing Wisely recommendations address PIMs. Specifically, proton pump inhibitors (PPIs), a medicine used to reduce gastric acid, should be de-escalated to the lowest dose necessary to provide relief. Many older patients with diabetes are over-controlled, with blood sugar levels lower than recommended, yet remain on multiple diabetes medicines and may be able to use fewer medicines. These patients are also at higher risk of low blood sugar from insulin and sulfonylureas, and should have limited use of these agents. Finally, gabapentin is often used off-label to treat pain, with greatly increased use over the past several years. There are many barriers to deprescribing PIMs. Many interventions solely target the prescribing provider. Although some believe providers have primary responsibility for deprescribing, patient initiation of discontinuation conversations can effectively facilitate deprescribing. In a single-site pilot study, we successfully reduced PIMs by engaging VA Primary Care patients by providing them with Veteran-centric EMPOWER (“Eliminating Medications through Patient Ownership of End Results”) brochures. However, it is not known if this approach will be as successful for Veterans with other chronic conditions or at non-pilot sites. Aims – We propose three aims. 1) Examine the impact of a patient-centered intervention to change provider prescribing (the primary outcome), as determined by the frequency with which medications are either deprescribed or de-escalated. 2) Examine the effect of a patient-centered intervention on engaging patients, via post-visit surveys of Veterans’ interaction with the brochures and their influence on deprescribing discussions and deprescribing. 3) Using qualitative methods, identify key organizational contextual factors related to intervention fidelity, feasibility, acceptability, and appropriateness to support future implementation. Methods and Innovation – We propose a multisite quasi-experimental trial using a Hybrid Type I Effectiveness-Implementation design of providing EMPOWER brochures directly to Veterans who may be deprescribing candidates for three cohorts of PIMs (PPIs, diabetes medications, and gabapentin). We will mail brochures in advance of scheduled primary care visits, unlike distribution methods used in other studies. Our primary outcome will be the composite of deprescribing and de-escalation of target medications, identified in pharmacy dispensing records of the Corporate Data Warehouse (Aim 1). Mail-based surveys sent after the scheduled primary care visit will assess patient engagement with the brochure and its impact on patient- provider communication (Aim 2). Finally, qualitative data from clinicians and staff addressing Proctor’s Implementation Outcomes will provide the foundation for future implementation strategies (Aim 3). Significance and Next Steps – Our study directly addresses multiple Veteran Care Priorities, including health care value, primary care practice, quality/safety, and Whole Health, and is aligned with current VA initiatives to prioritize patient preferences via individually-tailored, proactive care plans. The proposed work is strongly supported by Pharmacy Benefits Management and Office of Patient Centered Care and Cultural Transformation, which will facilitate the dissemination of findings to improve the quality and safety of medication use within VA. By study end, we will have established the effectiveness of an innovative, low-tech, patient-focused intervention to promote deprescribing of commonly used medications for three populations, thereby directly improving quality, safety, and value of VA care while also setting the stage for wider implementation and generalization of this approach to other potentially inappropriate medications.