Optimizing Appropriate Use of Medications for Veterans

我们选择了优化用药作为我们QUERI计划的主旨 作为实施重点的支持和提供商网络。我们的建议将建立在现有的强大基础上 项目负责人之间的关系(他们有成功实施QUERI项目的悠久历史)， 以及我们的运营合作伙伴，包括药房福利管理(PBM)、初级保健(PC)和 特殊护理服务。 主要计划目标：优化退伍军人管理局普通护理和患者导向护理中的药物管理 特别是使用药房网络和决策支持工具的团队。 虽然退伍军人管理局已经实施了许多干预措施来提高药物安全性，但药物管理已经 还有很大的改进空间。医学研究所的几项建议，包括Wide 决策支持的可用性和更多的药房参与处方还没有广泛 在退伍军人事务部实施。2011年，12%的退伍军人被开出了一种潜在的不适当药物 每年6%的发病率(新的不当用药)。药品质量差异很大 在退伍军人管理局中已经注意到了处方，这与普通人群的情况相当。也有不同的在 退伍军人管理局跨疾病州的处方质量。 相关目标：价值：我们的基本原则是通过所有药物促进高价值的临床护理 相关干预措施。我们将只建议扩展或设计针对以下护理策略的干预措施 被认为是“合理的”价值(收益与成本的比率)。我们计划提高高价值产品的利用率 药物，通过以下方式减少低价值药物的使用并提高用药安全性： 1)PBM用药评价跟踪器(MUET)的优化和扩展。(项目1) 2)实施PC常用药临床决策支持。(项目2) 3)当地为期一年的项目：确定针对患者的VISN 21药房仪表盘的最佳使用 统一的护理团队。(项目3) 这些项目包括创新(临床决策支持、实践社区的使用、开发 新的药物使用评估跟踪器)和对现有实施做法的评估。通过采取 不同设施实施MUET计划时进行的自然实验的优势 和VISN 21 Pharmacy Dashboard不同，我们将能够检查各种 实施战略的一部分。 实施科学焦点：我们选择的实施重点领域是提供者的使用 网络。如下文实施核心部分所述，通过我们之前的查询工作，我们拥有 展示了(在随机试验中)提供商网络的QUERI便利化如何成功地推出 退伍军人保健系统中的国家倡议(医院到家庭)。我们的结果表明，提供商网络 可以补充自上而下的实施战略，以改善对退伍军人的护理。这样的网络是一个 未实现的改善护理的机会，退伍军人管理局在开发和使用它们方面具有独特的地位。 QUERI计划的一个长期目标是优化基础设施和实施战略，使用当地 提供者(项目1中的药剂师)、临床决策支持(项目2)和仪表板数据(项目3) 可用于除药物管理之外的各种临床决策，如启发患者 护理或监测多发性疾病患者功能状态的目标。因此，虽然我们的节目 直接应用于药物管理，开发和测试的方法广泛适用于退伍军人管理局的医疗保健 并解决退伍军人管理局卓越蓝图对利用信息技术和分析的关注，同时 营造持续学习的环境。

We have selected optimization of medication use as the main theme of our QUERI Program with decision support and provider networks as foci of implementation. Our proposal will build upon existing strong relationships between the project leads (who have a long history of conducting successful QUERI projects), and our operations partners including Pharmacy Benefits Management (PBM), Primary Care (PC), and Specialty Care Services. Primary Program Goal: To optimize medication management in the VA general and Patient Aligned Care Teams in particular using pharmacy networks and decision support tools. While the VA has implemented many interventions to improve medication safety, medication management has significant room for improvement. Several recommendations by the Institute of Medicine, including the wide availability of decision support and more pharmacy involvement in prescribing have not been widely implemented in the VA. In 2011, 12% of Veterans were prescribed a potentially inappropriate medication with an incidence (new inappropriate medication) of 6% per year. A large variation in the quality of medication prescribing has been noted in the VA which is comparable to the general population. There is also variation in quality of prescribing across disease states in the VA. Associated Goal: Value: Our underlying principle is to promote high value clinical care with all medication related interventions. We will only recommend expansion of, or design interventions for, care strategies that are considered a “reasonable” value (ratio of benefit and cost). We plan to improve use of high value medications, decrease use of low-value medications and improve medication safety through: 1) Optimization and expansion of the Medication Use Evaluation Tracker (MUET) of PBM. (Project 1) 2) Implementation of Clinical Decision Support for medications commonly prescribed in PC. (Project 2) 3) Local One-Year Project: Determine optimal use of the VISN 21 Pharmacy Dashboard targeting Patient Aligned Care Teams. (Project 3) These projects include both innovation (clinical decision support, use of communities of practice, development of a new Medication Use Evaluation Tracker) and evaluation of existing implementation practices. By taking advantage of natural experiments that have occurred as different facilities implemented the MUET program and VISN 21 Pharmacy Dashboard differently, we will be able to examine effectiveness and value of a variety of implementation strategies. Implementation Science Focus: Our chosen area of focus for implementation is the use of provider networks. As described below in the Implementation Core Section, through our prior QUERI work we have shown (in a randomized trial) how QUERI facilitation of a provider network can be successful in rolling out a national initiative (Hospital to Home) in the VA health system. Our results demonstrate that Provider networks can complement top down implementation strategies to improve care for Veterans. Such networks are an unrealized opportunity to improve care, and the VA is uniquely positioned to develop and use them. A long-term goal of the QUERI Program is to optimize infrastructure and implementation strategies using local providers (pharmacists in Project 1), clinical decision support (Project 2) and, dashboard data (Project 3) that can be used for a variety of clinical decisions beyond medication management such as elicitation of patient goals of care or monitoring functional status in patients with multiple morbidities. Thus, while our program applies directly to medication management, the methods developed and tested apply broadly to VA health care and address VA's Blueprint for Excellence's focus on leveraging information technologies and analytics while fostering an environment of continuous learning.