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

 描述(由申请人提供)： 在退伍军人管理局内外，不适当的药物使用都很常见，大约20%-25%的65岁或以上的退伍军人受到影响。因此，VHA对美国内科委员会的选择明智活动表现出了极大的兴趣，该活动要求医学会在其专业中确定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，而且成本高昂。其中一个明智的建议是，建议不要对某些类型的肺动脉高压(PH)不适当地使用血管扩张剂，如磷酸二酯酶-5-抑制剂(PDE5i)。这些药物价格昂贵，如果使用不当可能会有害。在我们的试点工作中，我们发现从2005财年到2012财年，超过4000名退伍军人接受了PDE5i的PH治疗，不同地点不适当使用的频率变化了100倍。为了减少不适当的处方，我们必须首先了解围绕着为PH开PDE5i的决策的驱动因素，以及与其在VA中使用相关的结果。这项工作将找出如何减少不适当处方的经验教训，这些经验可用于取消使用其他几乎没有好处和潜在危害的高成本药物。我们提出了一项混合方法研究，有以下三个具体目标：1：确定患者-，临床医生-， 以及不适当使用PDE5i治疗PH的现场一级决定因素2：评估在当地情况下使用PDE5i治疗PH的处方和批准过程，并确定最佳实践3：评估不适当使用PDE5i治疗PH的结果。本研究的目的包括：目的1：利用全国VA数据和相关的医疗保险报销，我们将建立混合效应回归模型来评估不适当地使用PDE5i治疗PH的相关因素，并将使用PDE5i的患者与未接受PDE5i的相似患者进行比较。目标2：通过方案审查和对关键信息者(患者、临床医生、药剂师、 我们将对患者提供者和跨专业流程进行定性评估，以决定在6个VA站点(3个高利用率，3个低利用率)使用PDE5i进行PH治疗。目标3：我们将形成有或没有的PH患者队列 不适当地接收PDE5i，并使用国家摘要数据确定结果。将在两个队列中比较重要结果的风险，包括死亡率、住院和PDE5i的不良反应。我们将执行倾向分数匹配，以调整潜在的混淆。促进安全和有效的处方是VHA的主要目标，也是我们在药房福利管理办公室和国家肺部医学项目办公室的业务合作伙伴的主要目标。这项建议将为将来制定和实施有针对性的策略以减少不适当的PDE5i用于PH的建议奠定基础。此外，这项工作将作为一个一般性的测试案例，以了解几个因素如何影响处方：1)指南、退伍军人政策和个别患者护理之间的紧张关系，2)如何处理双重护理患者的非退伍军人处方，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。这项工作与蓝图中提出的停止实施无效护理的呼吁是一致的 卓越(策略2)。

 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).