Engaging Patients to Promote Deprescribing

让患者参与促进取消处方

• 批准号: 10607989
• 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/10607989
• 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 Preferences; Patient-Centered Care; Patients; Pharmaceutical Preparations; Pharmacy facility; Pilot Projects; Population; 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; clinical decision support; clinical practice; cohort; compliance behavior; contextual factors; cost; data warehouse; design; diabetic patient; effectiveness/implementation design; future implementation; gabapentin; high risk; implementation outcomes; implementation strategy; implementation/effectiveness; 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 care patient; primary care practice; primary care visit; primary outcome; provider-level barriers; system-level barriers; treatment as usual; whole health

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措施，以减少潜在的不适当 尽管有药物（PIM），许多退伍军人仍然是处方药，提供很少的好处，把他们放在 不必要的药物不良事件（ADE）风险。减少PIM的一个机制是通过取消处方， 基于去实现的方法，以深思熟虑地停止患者当前处方的药物。 许多明智选择的建议解决PIM。具体而言，质子泵抑制剂（PPI）， 用于减少胃酸的药物，应逐渐减少至提供缓解所需的最低剂量。 许多老年糖尿病患者控制过度，血糖水平低于推荐水平，但 继续使用多种糖尿病药物，并可能使用更少的药物。这些患者也在 胰岛素和磺脲类药物引起的低血糖风险较高，应限制使用这些药物。 最后，加巴喷丁通常用于标签外治疗疼痛，在过去几年中使用量大大增加。 取消PIM处方有许多障碍。许多干预措施仅针对处方提供者。 尽管有些人认为提供者对取消处方负有主要责任，但患者开始 中止对话可以有效地促进撤销处方。在一项单中心试点研究中，我们 通过为VA初级保健患者提供以退伍军人为中心的 EMPOWER（“通过最终结果的患者所有权消除药物”）手册。但据 不知道这种方法是否会成功的退伍军人与其他慢性疾病或在非试点网站。 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 处方（主要结局），由药物使用频率决定， 取消处方或降级。2)检查以患者为中心的干预对患者参与的影响， 通过对退伍军人与小册子的互动及其对取消处方的影响的访问后调查， 讨论和取消处方。3)使用定性方法，识别关键的组织背景因素 与干预的保真度、可行性、可接受性和适当性有关，以支持未来的实施。 方法和创新-我们提出了一个多地点准实验性试验，使用混合I型 主动性-直接向退伍军人提供EMPOWER小册子的实施设计， 停用三组PIM（PPI、糖尿病药物和加巴喷丁）的候选药物。我们将邮寄 与其他研究中使用的分发方法不同，在计划的初级保健访问之前分发小册子。我们 主要结局将是目标药物的取消处方和降级的复合结局， 公司数据仓库的药房配药记录（目标1）。邮件调查在 计划的初级保健访视将评估患者对手册的参与及其对患者的影响- 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了普罗克特的 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-我们的研究直接解决了多个退伍军人护理优先事项，包括健康 护理价值、初级保健实践、质量/安全和整体健康，并与当前的VA计划保持一致， 通过个性化定制的主动护理计划优先考虑患者偏好。拟议的工作是强有力的 由药房福利管理和以患者为中心的护理和文化办公室支持 转型，这将有助于传播调查结果，以提高质量和安全性， 在VA中使用药物。到研究结束时，我们将建立一个创新的，低技术的， 以患者为中心的干预措施，以促进三个人群的常用药物处方， 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VA护理奠定了基础。 将这种方法推广到其他可能不合适的药物。