Implementation Evaluation of PACT Pharmacy Management of Heart Failure in VISN 21

VISN 21 心力衰竭 PACT 药房管理实施评价

• 批准号: 10753388
• 负责人: Paul Heidenreich
• 金额: --
• 依托单位: VETERANS ADMIN PALO ALTO HEALTH CARE SYS
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-04-01 至 2026-03-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10753388
• 关键词: Address; Adherence; Adoption; Adrenergic beta-Antagonists; African American population; Appointment; Cardiology; Caring; Clinical; Cluster randomized trial; Complex; Dangerousness; Data; Dose; EFRAC; Emergency department visit; Evaluation; Evidence based practice; Feedback; Glucose Transporter; Goals; Guidelines; Health Services Accessibility; Healthcare Systems; Heart failure; Hospitalization; Hospitals; Impact evaluation; Improve Access; Intervention; Knowledge; Leadership; Learning; Life; Measures; Medical; Medical center; Medication Management; Methods; Mineralocorticoid Receptor; Monitor; Morbidity - disease rate; Outcome; Patient-Focused Outcomes; Patients; Pharmaceutical Preparations; Pharmacists; Pharmacy facility; Primary Care; Process; Protocols documentation; Provider; Quality of Care; Randomized; Reach, Effectiveness, Adoption, Implementation, and Maintenance; Recommendation; Reporting; Resources; Safety; Site; Sodium; Specialist; Standardization; Testing; Time; Titrations; Veterans; Wait Time; Work; adverse drug reaction; antagonist; cost; dashboard; data warehouse; hospital readmission; implementation cost; implementation evaluation; improved; improved outcome; inhibitor; innovation; interest; member; mortality; patient population; primary care practice; primary care provider; primary outcome; randomized trial; response; satisfaction; secondary outcome; side effect; tool

Justification: Heart failure (HF) is a common condition in the VA, with high morbidity and mortality. Accordingly, heart failure hospitalization and mortality are a focus of VA Safety Analytics for Improvement and Learning (SAIL). Furthermore, heart failure medical treatment is complex as there are now four classes of medications known to independently prolong survival and are recommended to be used together. Several medications require titration to recommended doses while monitoring for uncommon but dangerous side effects. A national HF dashboard is available to track guideline recommended therapy and shows many patients are not receiving optimal care. Pharmacist initiation and titration of medications through a protocol overseen by a specialist, has been found to improve recommended care in multiple randomized trials. However, few VA sites have fully implemented this practice for patients with heart failure. Accordingly, VISN 21 leadership has made increased quality of heart failure care through pharmacist management a priority. Several management tools have already been created and made available to pharmacists. The VISN’s goal is to test an audit and feedback intervention to expand pharmacy management. Hypothesis: Audit and feedback will increase PACT Pharmacy medication management for heart failure within VISN 21. Gaps Addressed (Knowledge and Practices). A National HF Dashboard shows many patients are not receiving optimal HF care within VISN21. Innovation. The use of PACT pharmacists to provide protocolized care for HF may increase quality of care, improve outcomes and free up primary care providers allowing them to focus on other patient issues. Given that patients are often referred to VA Cardiology for this medication initiation, pharmacist HF management can also improve access to VA Cardiology. Evaluation Specific Aims: AIM 1) Using a cluster randomized trial, determine the impact of audit and feedback as an intervention to increase implementation of PACT pharmacist management of HF. Hypothesis 1: VISN 21 sites randomized to audit and feedback will have greater use of PACT pharmacist HF management. AIM 2) Determine facilitators, barriers, fidelity, and cost of implementation AIM 3) At the VISN21 and national level, determine if increased use of pharmacist HF management is associated with increased use of guideline recommended therapies, improved adherence to therapy, improved access, and improved patient outcome. Hypothesis: Hospitalizations for HF will be reduced at sites with greater use of pharmacist medication management of HF. Hypothesis: Appropriate use of recommended doses for HF medication, as determined by the VA National HF Dashboard will be improved at sites with greater use of PACT pharmacist medication management. Project Methods AIM 1: VISN 21 sites (CBOCs and medical centers) will be randomized to audit and feedback (yes or no for 12 months of audit and feedback). If found to be successful at 12 months, audit and feedback will be provided to all sites. The primary outcome will be the number of HF patients managed by pharmacists per month per PACT team. Secondary outcomes will include the number of HF medication changes made by pharmacists per month per PACT team, and resource use (pharmacist and other staff time) . AIM 2: We will examine implementation of PACT pharmacy HF management using the RE-AIM framework including reach and adoption, analysis of barriers, facilitators, and provider satisfaction. AIM 3: We will compare facilities with high rates of PACT pharmacy HF management and compare these to similar sites with low rates of PACT pharmacy HF management in their use of guideline recommended life-prolonging medications, mortality, hospitalization, access to care and adherence to therapy. Use of recommended medications will be determined from a national medication dashboard for Veterans with HF. We will determine hospitalization, mortality, adherence to medications, and access to cardiology care using data from the Corporate Data Warehouse.

依据：心力衰竭（HF）是VA中的常见疾病，发病率和死亡率较高。 因此，心力衰竭住院和死亡率是VA安全性分析改善的重点， 学习（SAIL）。此外，心力衰竭医疗是复杂的，因为现在有四类心力衰竭治疗。 已知可以独立延长生存期的药物，建议一起使用。几 药物需要滴定到推荐剂量，同时监测不常见但危险的副作用 方面的影响.国家HF仪表板可用于跟踪指南推荐的治疗，并显示许多 病人没有得到最佳护理。药剂师通过方案启动和滴定药物 在专家的监督下，在多个随机试验中发现可以改善推荐的护理。 然而，很少有VA研究中心对心力衰竭患者完全实施这种做法。因此，VISN 21 领导层已将通过药剂师管理提高心力衰竭护理质量作为优先事项。 已经创建了几个管理工具，并提供给药剂师。VISN的目标是 测试审计和反馈干预，以扩大药房管理。 假设：审计和反馈将增加PACT药房对心力衰竭的药物管理， 第二十一章.弥补差距（知识和做法）。国家HF仪表板显示许多患者 在VISN 21内未接受最佳HF护理。创新使用PACT药剂师提供 HF的协议化护理可以提高护理质量，改善结局，并解放初级保健提供者 让他们专注于其他病人的问题。鉴于患者经常被转诊到VA心脏科， 开始药物治疗时，药剂师HF管理也可以改善VA心脏病学的可及性。评价 具体目的：目的1）使用随机分组试验，确定审计和反馈的影响， 增加HF PACT药剂师管理实施的干预措施。假设1：VISN 21 随机接受稽查和反馈的研究中心将更多地使用PACT药剂师HF管理。AIM 2） 确定促进者、障碍、保真度和实施成本AIM 3）在VISN 21和国家一级， 确定增加使用药剂师HF管理是否与增加使用指南相关 推荐的治疗，改善的治疗依从性，改善的可及性和改善的患者结果。 假设：在更多使用药剂师药物的研究中心，HF住院治疗将减少 HF的管理假设：适当使用HF药物的推荐剂量， 将在更多使用PACT药剂师药物的研究中心改进VA国家HF仪表板 管理AIM 1：VISN 21个研究中心（CBOC和医疗中心）将被随机分配至 审计和反馈（12个月的审计和反馈是或否）。如果在12个月时发现成功， 将向所有研究中心提供审计和反馈。主要结局为HF患者数量 每个PACT团队每月由药剂师管理。次要结局将包括HF数量 每个PACT团队药剂师每月进行的药物变更，以及资源使用（药剂师和其他 工作人员时间）。目的2：我们将使用RE-AIM检查PACT药房HF管理的实施情况 框架，包括覆盖范围和采用率，障碍分析，促进者和提供者满意度。目标3：我们 将比较PACT药房HF管理率高的设施，并将其与类似地点进行比较 在使用指南推荐的延长生命药物时， 药物、死亡率、住院、获得护理和坚持治疗。采用所推荐的 药物将从国家药物仪表板与HF退伍军人确定。我们将确定 住院率、死亡率、药物依从性和心脏病护理的可及性， 企业数据仓库。