Determining and targeting reasons for low statin use to improve guideline-concordant statin therapy in high-risk patients

背景：最佳的他汀类药物治疗与慢性阻塞性肺疾病患者心血管事件风险降低有关。 已确诊的心血管疾病(CVD)。退伍军人事务部外部同行审查计划(EPRP)还建议 中-高强度他汀类药物在心血管疾病患者中的应用。我们已经表明，有很大比例的退伍军人患有 心血管疾病(41%)正在接受次佳的他汀类药物治疗。指南一致的他汀类药物治疗超过5年可能 有可能预防20611起血管事件，包括3435例患有心血管疾病的退伍军人死亡。次优他汀类药物应用 可能是由于他汀类药物相关的副作用或由于提供者的临床惰性。我们已经证明了副作用 和他汀类药物不耐受在结构化数据集中没有被很好地捕获，并且通常在免费的 临床医生提供的文本说明。因此，重要的是找出他汀类药物利用率不佳的原因，并 设计一项干预措施，以增加适当的CVD患者接受指南推荐的护理。 目标：我们的目标是从当前可用的结构化数据集中检查用药模式 并使用自然语言处理(NLP)来识别不符合指南的CVD患者 他汀类药物治疗因他汀类药物不耐受或提供者临床惰性。我们还将进行一项试点研究，以提供 以点对点通信辅助的形式向患者对齐的护理团队(PACT)提供简洁的信息 它瞄准了这些差距。目标1：确定退伍军人的原因(过敏、不耐受或临床惰性) 心血管疾病没有接受指南推荐的基于结构化数据和自动化的他汀类药物治疗 使用NLP进行信息提取。目标2：了解提供者和患者对他汀类药物不耐受的理解 并通过定性访谈描述提供者应对不耐受的脂质管理策略。 在这些采访的基础上，我们将提炼一份针对PACT提供商的简明沟通辅助工具 这将使他们能够有效地启动和/或滴定CVD患者的他汀类药物到循证剂量 (包括对他汀类药物不耐受的患者)。目标3：在休斯顿试行一款通讯辅助设备 退伍军人事务部纳什维尔协定确定其使用是否与指南一致性他汀类药物的增加有关 治疗用法在脑血管病患者中的应用与常规护理的比较。 方法：对于目标1，我们将从整个VA系统中随机识别CVD患者(最佳情况下为500例 他汀类药物，500人服用他汀类药物，但剂量低于中等强度，500人不服用他汀类药物)并随机分配 将他们纳入训练和测试集。然后，我们将训练我们的NLP系统，以实现对 &gt；90%，与人工审图相比。在目标2中，我们将对供应商和 VISN 16中的患者引出他们对与他汀类药物相关的临床惰性和不耐受的看法。这些 面谈将有助于改进交流辅助工具的内容，以便在试点期间使用 拟议研究的阶段。在目标3中，我们将与休斯顿和纳什维尔VAMC协议进行试点试验 作为干预点。所有在干预地点的PARTS都将收到帮助沟通的帮助 在CVD患者中使用他汀类药物启动和/或滴定，服用次佳的他汀类药物。在通常的护理地点 (附属于休斯顿和纳什维尔VAMC的社区门诊诊所)，PACT提供者将仅 收到他们的CVD患者服用次优他汀类药物的比例的季度报告。我们的主要结果是 接受最佳(至少中等强度)他汀类药物治疗的CVD患者比例的变化。 对退伍军人医疗保健的预期影响：我们的结果将非常重要，因为它们将确定 大多数高危退伍军人由于不耐受和临床惰性而没有接受最佳的他汀类药物治疗。我们的 沟通援助将确定在高危退伍军人中启动或滴定他汀类药物的策略，这些退伍军人可能会从 通过解决患者的不耐受性和临床惰性，从这种拯救生命的疗法中获益最多。最后， 这些结果将对退伍军人管理局医疗保健系统识别高危患者具有真正的他汀类药物具有重要意义 不耐受“谁将是FDA最近批准的昂贵新药的未来候选人。

Background: Optimal statin therapy is associated with a lower risk of cardiovascular events in patients with established cardiovascular disease (CVD). The VA External Peer Review Program (EPRP) also recommends moderate-high intensity statins in patients with CVD. We have shown that a large proportion of Veterans with CVD (41%) are on suboptimal statin therapy. Guideline concordant statin treatment over 5 years could potentially prevent 20,611 vascular events including 3,435 deaths in Veterans with CVD. Suboptimal statin use may be due to statin associated side effects or due to provider clinical inertia. We have shown that side effects and statin intolerance are not well captured in the structured datasets, and are usually documented in the free text notes by clinicians. It is therefore important to identify the reasons for suboptimal statin utilization and to design an intervention to increase receipt of guideline recommended care in appropriate CVD patients. Objective: Our objective is to examine patterns of medication use from currently available structured datasets and the use of natural language processing (NLP) to identify the CVD patients not on a guideline concordant statin therapy due to statin intolerance or provider clinical inertia. We will also perform a pilot study providing succinct information to patient aligned care teams (PACTs) in the form of a point-of-care communication aid which targets these gaps. Aim 1: To identify reasons (allergy, intolerance, or clinical inertia) Veterans with CVD are not receiving guideline-recommended statin therapy based on structured data and automated information extraction with NLP. Aim 2: To understand provider and patient understanding of statin intolerance and to describe providers' lipid management strategies addressing intolerance through qualitative interviews. Based on these interviews, we will refine a succinct communication aid targeted towards PACT providers which will allow them to effectively initiate and/or titrate statins to evidence-based doses in CVD patients (including patients who are intolerant to statins). Aim 3: To pilot test a communication aid in Houston and Nashville VA PACTs to determine whether its use is associated with an increase in guideline-concordant statin therapy use in patients with CVD compared to usual care. Methods: For Aim 1, we will randomly identify CVD patients from throughout the VA system (500 on optimal statins, 500 on statin but on less than moderate-intensity dose, and 500 not on a statin) and randomly partition them into training and a test set. We will then train our NLP system to achieve a sensitivity and specificity of >90%, compared with manual chart review. In Aim 2, we will conduct qualitative interviews with providers and patients in VISN 16 to elicit their perspectives on clinical inertia and intolerance related to statins. These interviews will help facilitate the refinement of the content of the communication aid for use during the pilot phase of the proposed study. In Aim 3, we will conduct a pilot trial with Houston and Nashville VAMC PACTs serving as the intervention sites. All PACTs at the intervention sites will receive the communication aid to assist them with statin initiation and/or titration in patients with CVD on suboptimal statins. At usual care sites (community based outpatient clinics affiliated with the Houston and Nashville VAMC), PACT providers will only receive a quarterly report of the proportion of their CVD patients on suboptimal statins. Our primary outcome is the change in the proportion of CVD patients receiving optimal (at least a moderate intensity) statin therapy. Anticipated Impact on Veteran's Healthcare: Our results will be important as they will identify the vast majority of high-risk Veterans not on optimal statin therapy due to intolerance versus clinical inertia. Our communication aid will identify strategies to initiate or titrate statins in high-risk Veterans who stand to derive the most benefit from this life saving therapy by addressing both patient intolerance and clinical inertia. Finally, these results will be important for the VA Health Care System to identify high-risk patients with “true statin intolerance” who will be future candidates for highly expensive new drugs recently approved by the FDA.