Improved Cardiovascular Risk Reduction to Enhance Rural Primary Care:I-CARE

描述（由申请人提供）：心血管疾病（CVD）每天导致2200名美国人死亡，每39秒就有一人死亡。有证据表明，通过更好地管理风险因素可以预防这些死亡，然而，许多风险因素仍然不受控制。心血管疾病患者具有高度的复杂性，往往有许多慢性疾病。以患者为中心的医疗之家包括自我管理、个性化健康记录和团队护理是一种改善多种慢性疾病患者护理的策略。管理式医疗机构发现，集中管理心血管风险服务可以降低死亡率。目前尚不清楚在缺乏临床药剂师或专业护士的私人诊所是否会实施包括癌症筛查在内的预防健康和心血管风险服务（PHCVRS）。我们的长期目标是通过团队护理改善对复杂病史患者的管理。我们开创了采用集群随机试验来评估团队护理实施和指南依从性的策略。本应用程序的目的是开展一项多中心、集群随机研究，利用集中式PHCVRS来支持更多缺乏大型综合健康计划的农村地区的私人医疗办公室。这项研究的标题是“改善心血管风险降低，加强农村初级保健：ICARE”。我们将对爱荷华研究网络（IRENE）的12个初级保健办公室进行分层和随机分组，将其纳入PHCVRS或常规护理，并招募300名受试者。我们还将在每个办公室随机选择25名患者（n=300，总n=600）进入被动观察组，这将使我们能够确定干预措施在未暴露患者中更广泛扩散的程度。我们的中心假设是，PHCVRS将显著提高对五个国家组织支持的指南优势指标的依从性。本研究的基本原理是，采用一种新的方法来改善心血管疾病和癌症筛查的管理，将导致创新的策略，在整个美国的卫生系统中得到更广泛的采用。我们将实现我们的目标，并通过以下具体目标检验我们的中心假设：目标1：确定基于网络的PHCVRS是否将在私人初级保健办公室中实施。目的2：确定PHCVRS干预是否扩散到整个干预办公室。我们的方法是创新的，因为它会提出这样的问题：“PHCVRS模式会成功实施吗？”以及“护理管理是否有效？”这些问题还没有解决患者的多重慢性疾病在私人执业。这项研究的设计是新颖的，因为它将：1)在小型私人诊所中使用聚类随机设计来测试该模型，2)评估效果是否可以长期持续，3)评估“被动观察组”以确定干预是否在整个实践中扩散。

DESCRIPTION (provided by applicant): Cardiovascular disease (CVD) causes 2,200 deaths in Americans every day, with one death every 39 seconds. There is evidence that these deaths can be prevented with better risk factor management, however, many risk factors remain uncontrolled. Patients with CVD have high levels of complexity and tend to have numerous chronic conditions. The Patient-Centered Medical Home including self- management, personalized health records and team-based care is a strategy to improve care for patients with multiple chronic conditions. Managed care organizations have found that a centralized cardiovascular risk service managed can reduce mortality. It is not known if a Prevention Health & Cardiovascular Risk Service (PHCVRS) including cancer screening would be implemented in private office practices that lack clinical pharmacists or specialized nurses. Our long-range goal is to improve the management of patients with complex medical histories with team-based care. We have pioneered strategies to evaluate team care implementation and guideline adherence using cluster-randomized trials. The objective of this application is to conduct a multi-center, cluster-randomized study utilizing a centralized PHCVRS to support private medical offices in more rural areas that lack large integrated health plans. This study is titled "Improved Cardiovascular Risk Reduction to Enhance Rural Primary Care: ICARE." We will stratify and randomize 12 primary care offices in the Iowa Research Network (IRENE) to PHCVRS or usual care and enroll 300 subjects. We will also randomly select 25 patients per office (n=300, total n=600) into a passive observation group that will allow us to determine the extent to which the intervention diffuses more broadly for unexposed patients. Our central hypothesis is that the PHCVRS will significantly improve adherence to The Guideline Advantage metrics that are supported by five national organizations. The rationale for this proposed study is that implementation of a novel approach to improve management of CVD and cancer screening will lead to innovative strategies for broader adoption by health systems throughout the U.S. We will accomplish our objectives and test our central hypothesis with the following specific aims: Aim 1: To determine if a web-based PHCVRS will be implemented within private primary care offices. Aim 2: To determine if the PHCVRS intervention diffuses throughout the intervention offices. Our approach is innovative because it will ask the questions: "Will the PHCVRS model be successfully implemented?" as well as "Is care management effective?" These questions have not been addressed for patients with multiple chronic conditions in private practice. This study design is novel because it will: 1) be the most robust study to test this model using a cluster randomized design in small private practice clinics, 2) evaluate whether the effect can be sustained long-term, and 3) evaluate a "passive observation group" to determine if the intervention diffuses throughout the practice.