Engaging Patients to Promote Deprescribing

让患者参与促进取消处方

• 批准号: 10359059
• 负责人: Amy Linsky
• 金额: --
• 依托单位: VA BOSTON HEALTH CARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2020
• 资助国家: 美国
• 起止时间: 2020-03-01 至 2024-08-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10359059
• 关键词: Academic Detailing; Address; Adverse drug event; Blood Glucose; Caring; Characteristics; Chronic; Data; Deimplementation; Diabetes Mellitus; Dose; Drug Prescriptions; Education; Effectiveness; Foundations; Frequencies; Gastric Acid; Health; Healthcare; Hybrids; Hypoglycemia; Individual; Insulin; Intervention; Medicine; Methods; Outcome; Ownership; Pain; Pamphlets; Patient Care; Patient Preferences; Patient-Centered Care; Patients; Pharmaceutical Preparations; Pharmacy facility; Pilot Projects; Population; Primary Health Care; Proctor framework; Proton Pump Inhibitors; Provider; Qualitative Methods; Quality of Care; Quasi-experiment; Randomized Controlled Trials; Recommendation; Records; Reporting; Resources; Risk; Safety; Schedule; Site; Sulfonylurea Compounds; Surveys; System; Testing; Veterans; Visit; Work; base; clinical decision support; clinical practice; cohort; compliance behavior; contextual factors; cost; data warehouse; diabetic patient; effectiveness implementation design; future implementation; gabapentin; high risk; implementation outcomes; implementation strategy; improved; innovation; intervention effect; medication safety; multi-site trial; off-label use; older patient; patient engagement; patient oriented; patient-clinician communication; patient-level barriers; pharmacy benefit; prevent; primary outcome; provider-level barriers; system-level barriers; treatment as usual

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.

背景-尽管有多个提供者和系统级干预，以减少潜在的不适当