A Novel Deprescribing Intervention for Heart Failure with Preserved Ejection Fraction (HFpEF): A Prototype for Older Adults with Multimorbidity and Polypharmacy

项目摘要 候选人：我的职业目标是改善患有多种慢性疾病的老年人的健康状况， 通过开发和严格测试合理的策略来改善药物处方， 实践;并成为一个独立的临床研究人员和老年心脏病的国家领导人。这 作为一名心力衰竭心脏病专家，这一领域与我特别相关，因为我照顾的老年人几乎 普遍有多种慢性疾病和多种药物。我作为这方面的新兴领导者的记录 多个主要作者和资深作者的手稿，作为主要研究者的4笔赠款， 包括一个GEMSSTAR，我作为威尔康奈尔心脏衰竭的创始主任的职位， 保留射血（HFpEF）计划的老龄化，以及我作为主席的美国大学的作用， 心脏病学老年心脏病学科早期职业专业人员工作组。导师与环境： 该项目将在4名资金充足的调查人员的指导下进行，他们将贡献他们的 老年医学（Mark Lachs），老年心脏病学（Mathew Maurer）， 实施科学（Monika Safford）和N-of-1试验（Ian Kronish）。取消处方方面的顾问，共享 决策和生物统计学将提供额外的内容专业知识，以确保成功的 提出项目并促进我的职业发展。该项目将在支持性的 威尔康奈尔医学的环境，这表明了我作为一个发展的深刻承诺， 在过去的几年里，临床研究员。指导研究项目：尽管它的作用是一个不可分割的一部分 以病人为中心和目标一致的处方实践，取消处方很少被纳入临床 实践中遇到了一些障碍。为了改善以患者为中心的药物管理，需要 开发能够克服这些障碍的流程。本提案的目的是确定N- 作为一种务实的以患者为中心的药物优化方法， 取消处方的障碍-可能导致患者对继续或 停止服药。为了实现这一点，我将：1）确定一个可行的和务实的协议的关键特征 用于使用参与者参与的迭代设计方法来取消1个试验中的N个试验;以及2）确定 经调整的N-of-1方案对患者决策信心和取消处方的初步有效性，以及 3)确定在现实世界的临床中实施适应性N-of-1方案的促进因素和障碍 通过进行类型1混合有效性-实施试验来实践。我将通过使用这些工具来实现这些目标- 左室射血分数正常的心力衰竭阻滞剂（HFpEF）作为老年人的原型， 多药治疗和多药治疗。该建议将为未来的多中心随机对照试验提供信息 专注于改善患者报告的结果，并为我提供一个形成的机会，以获得 成为以患者为中心的药物管理的领先研究人员所需的知识和技能。

PROJECT SUMMARY Candidate: My career goal is to improve the wellbeing of older adults with multiple chronic conditions and polypharmacy by developing and rigorously testing rational strategies to improve medication prescribing practices; and to become an independent clinician investigator and national leader in Geriatric Cardiology. This area is particularly relevant for me as a heart failure cardiologist, as I care for older adults who almost universally have multiple chronic conditions and polypharmacy. My track record as an emerging leader in this area is evidenced by multiple lead- and senior-author manuscripts, 4 grants as the Principal Investigator including a GEMSSTAR, my position as the Founding Director of the Weill Cornell Heart Failure with Preserved Ejection (HFpEF) Program for the Aging, and my role as the Chair of the American College of Cardiology Geriatric Cardiology Section Early Career Professionals Working Group. Mentors and Environment: This project will be conducted under the mentorship of 4 well-funded investigators who will contribute their complementary expertise in Geriatrics (Mark Lachs), Geriatric Cardiology (Mathew Maurer), Implementation Science (Monika Safford), and N-of-1 trials (Ian Kronish). Advisors in deprescribing, shared decision making, and biostatistics will provide additional content expertise to ensure the success of the proposed project and catalyze my career development. This project will take place within the supportive environment of Weill Cornell Medicine, which has demonstrated a deep commitment to my development as a clinician-investigator for the past several years. Mentored Research Project: Despite its role as an integral part of patient-centric and goal-concordant prescribing practice, deprescribing is seldom incorporated into clinical practice due to several barriers. To improve patient-centered medication management, there is a need to develop processes that can overcome these barriers. The objective of this proposal is to determine whether N- of-1 trials—as a pragmatic patient-centered approach to medication optimization that can overcome key barriers of deprescribing— can lead to increased patient confidence regarding the decision to continue or discontinue a medication. To achieve this, I will: 1) determine key features of a feasible and pragmatic protocol for deprescribing N-of-1 trials using a stakeholder-engaged iterative design approach; and 2) determine the preliminary effectiveness of an adapted N-of-1 protocol on patient decision confidence and deprescribing, and 3) determine the facilitators and barriers of implementing an adapted N-of-1 protocol into real-world clinical practice by conducting a type-1 hybrid effectiveness-implementation trial. I will achieve these aims by using ß- blocker in heart failure with preserved ejection fraction (HFpEF) as a prototype for older adults with multimorbidity and polypharmacy. This proposal will inform a future multicenter randomized controlled trial focused on improving patient-reported outcomes, and provide a formative opportunity for me to obtain the knowledge and skills necessary to become a leading researcher on patient-centered medication management.