Implementation Evaluation of PACT Pharmacy Management of Heart Failure in VISN 21

理由：心力衰竭（HF）是VA的常见病，发病率和死亡率都很高。

Justification: Heart failure (HF) is a common condition in the VA, with high morbidity and mortality. Accordingly, heart failure hospitalization and mortality are a focus of VA Safety Analytics for Improvement and Learning (SAIL). Furthermore, heart failure medical treatment is complex as there are now four classes of medications known to independently prolong survival and are recommended to be used together. Several medications require titration to recommended doses while monitoring for uncommon but dangerous side effects. A national HF dashboard is available to track guideline recommended therapy and shows many patients are not receiving optimal care. Pharmacist initiation and titration of medications through a protocol overseen by a specialist, has been found to improve recommended care in multiple randomized trials. However, few VA sites have fully implemented this practice for patients with heart failure. Accordingly, VISN 21 leadership has made increased quality of heart failure care through pharmacist management a priority. Several management tools have already been created and made available to pharmacists. The VISN’s goal is to test an audit and feedback intervention to expand pharmacy management. Hypothesis: Audit and feedback will increase PACT Pharmacy medication management for heart failure within VISN 21. Gaps Addressed (Knowledge and Practices). A National HF Dashboard shows many patients are not receiving optimal HF care within VISN21. Innovation. The use of PACT pharmacists to provide protocolized care for HF may increase quality of care, improve outcomes and free up primary care providers allowing them to focus on other patient issues. Given that patients are often referred to VA Cardiology for this medication initiation, pharmacist HF management can also improve access to VA Cardiology. Evaluation Specific Aims: AIM 1) Using a cluster randomized trial, determine the impact of audit and feedback as an intervention to increase implementation of PACT pharmacist management of HF. Hypothesis 1: VISN 21 sites randomized to audit and feedback will have greater use of PACT pharmacist HF management. AIM 2) Determine facilitators, barriers, fidelity, and cost of implementation AIM 3) At the VISN21 and national level, determine if increased use of pharmacist HF management is associated with increased use of guideline recommended therapies, improved adherence to therapy, improved access, and improved patient outcome. Hypothesis: Hospitalizations for HF will be reduced at sites with greater use of pharmacist medication management of HF. Hypothesis: Appropriate use of recommended doses for HF medication, as determined by the VA National HF Dashboard will be improved at sites with greater use of PACT pharmacist medication management. Project Methods AIM 1: VISN 21 sites (CBOCs and medical centers) will be randomized to audit and feedback (yes or no for 12 months of audit and feedback). If found to be successful at 12 months, audit and feedback will be provided to all sites. The primary outcome will be the number of HF patients managed by pharmacists per month per PACT team. Secondary outcomes will include the number of HF medication changes made by pharmacists per month per PACT team, and resource use (pharmacist and other staff time) . AIM 2: We will examine implementation of PACT pharmacy HF management using the RE-AIM framework including reach and adoption, analysis of barriers, facilitators, and provider satisfaction. AIM 3: We will compare facilities with high rates of PACT pharmacy HF management and compare these to similar sites with low rates of PACT pharmacy HF management in their use of guideline recommended life-prolonging medications, mortality, hospitalization, access to care and adherence to therapy. Use of recommended medications will be determined from a national medication dashboard for Veterans with HF. We will determine hospitalization, mortality, adherence to medications, and access to cardiology care using data from the Corporate Data Warehouse.