Nudging Doctors to Collaborate with Pharmacists to Improve Medication Adherence

描述（由申请人提供）：对处方药的依从性差是普遍存在的，而且费用高昂。医生对患者依从性的评估是不准确的，这使得使用药房声明来识别不依从性变得很有吸引力。但研究清楚地表明，简单地向医生提供关于不依从的索赔数据是无效的，可能是因为不清楚应该采取什么行动，而且因为采取任何行动的时间和精力成本都很大。目前缺乏的是一种实用的方法，有效地将诊断信息和治疗专业知识整合到初级保健医生办公室的工作流程中，并有效地诱导医生采取行动。本研究的长期目标是开发有效连接药房福利经理（PBM），初级保健医生，临床药剂师，和病人的方式，提高药物依从性和病人的健康结果。该应用程序的总体目标是实现我们的长期目标的下一步，是对一种干预措施进行试点测试，该干预措施可及时向医生提供有关不依从的诊断信息，然后比较两种向初级保健医生及其患者提供药剂师服务的方法的有效性。利用智能选择架构的原理，在一个臂中，药剂师将联系患者作为默认选项（不需要医生采取任何行动），而在另一个臂中，药剂师仅在医生主动选择药剂师采取行动时才联系患者。我们的中心假设，这是在其他领域的工作强烈支持，是药剂师的干预时，药剂师将被咨询更频繁的默认结果，默认的药剂师干预将是最有益的依从性的结果。选择这种方法的理由是，从行为经济学的观察，即使是小成本在短期内可以阻止医生追求的行动过程中，有重要的长期利益。这项拟议中的研究与NIH的使命有关，因为对艾滋病等慢性病药物的依从性差是一个严重的全球性问题。本RC 4提案有三个具体目标：1）建立并测试开展本临床试验所需的技术和通信基础设施，2）开展并评价一项干预临床试验，比较向初级保健医生提供药剂师服务的方法，3）评价经济结局。这一建议意义重大，因为药物不依从性是一个常见且昂贵的问题，目前几乎没有有效的解决方案。它之所以具有创新性，是因为它将行为经济学的原则应用于药物依从性问题;因为它测试了一种将PBM、医生、患者和药剂师联系起来的通信架构;因为它将在一个松散的小团体实践联盟中进行;因为它包括对经济结果的分析。虽然这项试点研究的重点是糖尿病，高血压和高脂血症，但干预本身是广泛和交叉的，适用于任何医疗条件和所有护理环境。 公共卫生相关性：虽然实现慢性病患者的最佳健康结果需要患者坚持有效的药物治疗，但很少有简单有效的方法来实现这一目标。这项拟议的试点研究开发了一种创新的通信基础设施，将药房福利管理人员，医生，患者和药剂师联系起来，并使用行为经济学的原则来比较两种不同方式使用这种基础设施的有效性。虽然这项试点研究的重点是糖尿病，高血压和高脂血症，但干预措施适用于任何医疗条件和所有护理环境。

DESCRIPTION (provided by applicant): Poor adherence with prescription medications is ubiquitous and costly. Physicians' assessments of patients' adherence are inaccurate, which makes it attractive to use pharmacy claims to identify nonadherence. But research clearly shows that simply giving physicians claims data about nonadherence is ineffective, probably because it is not clear what action to take, and because the cost in time and energy of any taking action is great. What is currently lacking is a practical way to effectively integrate diagnostic information and treatment expertise into work flows in primary care physicians' offices, and an effective method of inducing physicians to act on it. The long term goal of this research is to develop systems that effectively connect pharmacy benefits managers (PBMs), primary care doctors, clinical pharmacists, and patients in ways that improve medication adherence and patients' health outcomes. The overall objective of this application, which is the next step toward attainment of our long term goal, is to conduct a pilot test of an intervention that delivers timely diagnostic information about nonadherence to physicians, and then compares the effectiveness of two ways to provide pharmacist services to primary care physicians and their patients. Taking advantage of the principle of intelligent choice architecture, in one arm the pharmacist will contact the patient as the default option (with no action required by the doctor), and in the other the pharmacist will contact the patient only if the doctor actively chooses that the pharmacist take action. Our central hypothesis, which is strongly supported by work in other fields, is that the pharmacist will be consulted more often when intervention by the pharmacist is the default outcome, and that the default pharmacist intervention will be the most beneficial for adherence outcomes. The rationale for choosing this approach is the observation, from behavioral economics, that even small costs in the short term can prevent physicians from pursuing a course of action that has important long term benefits. The proposed research is relevant to the NIH's mission because poor adherence with medications for chronic conditions like HIV is a serious, worldwide problem. This RC4 proposal has three Specific Aims: 1) Establish and test the technical and communications infrastructure required for the conduct of this clinical trial, 2) Conduct and evaluate a clinical trial of an intervention comparing methods of offering pharmacist services to primary care physicians, and 3) Evaluate economic outcomes. This proposal is significant because medication nonadherence is a common and costly problem for which there are currently few effective solutions. It is innovative because it applies principles from behavioral economics to the problem of medication adherence; because it tests a communications architecture that links PBMs, physicians, patients, and pharmacists; because it will take place in a loose alliance of small group practices; and because it includes analysis of economic outcomes. While this pilot study focuses on diabetes, hypertension, and hyperlipidemia, the intervention itself is broad and cross-cutting, and applicable to any medical condition and all care settings. PUBLIC HEALTH RELEVANCE: While achieving optimal health outcomes for persons with chronic medical conditions requires that patients adhere to effective medications, few simple and effective methods to accomplish this have been developed. This proposed pilot study develops an innovative communications infrastructure that links pharmacy benefits managers, physicians, patients, and pharmacists, and uses principles from behavioral economics to compare the effectiveness of two different ways to use this infrastructure. While this pilot study focuses on diabetes, hypertension, and hyperlipidemia, the intervention is applicable to any medical condition and all care settings.