Expanded Role of Primary Care Pharmacists in the Management of Heart Failure

扩大初级保健药剂师在心力衰竭治疗中的作用

• 批准号: 10425916
• 负责人: Paul Heidenreich
• 金额: --
• 依托单位: VETERANS ADMIN PALO ALTO HEALTH CARE SYS
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-10-01 至 2022-09-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10425916
• 关键词: Address; Admission activity; Adrenergic beta-Antagonists; African American population; Ambulatory Care Facilities; Angiotensin Receptor; Angiotensin-Converting Enzyme Inhibitors; Appointment; Businesses; Cardiology; Caring; Clinic; Communities; Complex; Dangerousness; Dose; Emergency department visit; Employee Engagement; Evaluation; Evidence based practice; Feedback; Free Will; Guidelines; Health Services Accessibility; Health system; Healthcare Systems; Heart failure; Hospitalization; Hospitals; Improve Access; Investments; Knowledge; Leadership; Learning; Manuals; Measures; Medical; Medical center; Medication Management; Methods; Monitor; Morbidity - disease rate; Outcome; Patients; Pharmaceutical Preparations; Pharmacists; Pharmacy facility; Primary Health Care; Protocols documentation; Provider; Quality of Care; Recording of previous events; Reporting; Role; Safety; Site; Standardization; Testing; Time; Titrations; Veterans; Wait Time; Work; adverse drug reaction; barrier to care; base; care outcomes; care providers; cost; dashboard; hospital readmission; implementation cost; implementation facilitation; implementation outcomes; implementation strategy; improved; innovation; meetings; member; mortality; operation; patient population; pharmacy benefit; pilot test; primary outcome; programs; randomized trial; satisfaction; side effect

Justification. Heart failure (HF) is a common condition in the VA, with high morbidity and mortality. Accordingly, HF hospitalization and mortality are a focus of VA Safety Analytics for Improvement and Learning (SAIL). Furthermore, HF medical treatment is complex as there are now four classes of medications known to independently prolong survival and are recommended to be used together (five for African Americans). Several medications require titration to recommended doses while monitoring for uncommon but dangerous side effects. Given the complexity of treatment and the insufficient number of cardiologists to manage this large patient population, standardized medication initiation and titration of medications by non-physicians has been tested as an adjunct to current primary care practice of patient aligned care teams (PACT). Pharmacist medication initiation and titration of medications has been found to improve recommended care in multiple randomized trials. However, few VA sites have implemented medication initiation and titration of medications for HF by PACT pharmacists. Hypothesis: Pharmacy medication initiation and titration of HF medications can be implemented successfully at two sites in VA Palo Alto HCS and will increase recommended use of three medication classes for Veterans with HF. Gaps Addressed (Knowledge and Practices). A National HF Dashboard is available to track guideline recommended therapy and shows many patients are not receiving optimal HF car e. Innovation. The use of PACT pharmacists to provide protocolized care for HF will free up primary care providers from this work allowing them to increase access to primary care. Given that patients are often referred to VA Cardiology for this task, pharmacist management can also improve access to VA Cardiology. Specific Aims 1) Implement pharmacist led protocolized care in PACTs for the initiation and titration of HF medications at two types of primary care sites. 2) Determine facilitators, barriers, fidelity and cost of implementation. 3) Demonstrate an impact on recommended HF care and increased access to VA Primary Care and VA Cardiology as a result of PACT pharmacist management. Project Methods We have partnered with pharmacy and PACT leadership at VA Palo Alto HCS in their use of PACT pharmacist HF medication management at one CBOC (Monterey, CA). In this project we will spread this practice to two types of sites: VA Palo Alto Medical Center based Primary Care Clinic (large) and the VA San Jose CBOC, CA (small). Implementation Strategies As part of the proposed project we (partnership of the VISN CMO Dr. Godbout and the QUERI Team) will 1) organize local champions, 2) facilitate spread to the two sites and 3) provide audit and feedback to PACT pharmacy and primary care leadership. We will bring together local champions (VA Pharmacy, VA Primary Care and VA Cardiology leadership) who will be shown results over time and will provide advice on how to modify the implementation for their site. To facilitate implementation, we will develop and provide an operation manual and toolkit that includes pharmacy medication management protocols. Evaluation Our evaluation will examine implementation (e.g. fidelity, barriers, facilitators, cost, provider satisfaction, employee engagement) and outcomes (fraction of patients meeting guideline recommended care, access). Description of primary outcomes/endpoints. The implementation outcomes will include the number of HF patients managed by pharmacists per month per PACT team, and number of medication changes made by PACT pharmacists per month per PACT team. Pharmacist and primary provider satisfaction and perceived burden with the expanded pharmacist role will be determined. Cost of implementation will be determined and compared with benefits (increased access, increased quality of care metrics) to provide both a business case analysis and return on investment. The care outcomes will be use of five VA recommended HF medication classes from the National VA HF Dashboard, access/wait times for PACT and VA Cardiology appointments, admission, readmission, mortality, emergency department visits and adverse drug reactions.

理由。心力衰竭 (HF) 是退伍军人管理局的常见病症，发病率和死亡率很高。 因此，心力衰竭住院和死亡率是 VA 安全分析改进和学习的重点 （帆）。此外，心力衰竭的治疗很复杂，因为目前已知有四类药物可以治疗心力衰竭。 独立延长生存期，建议联合使用（非裔美国人五种）。 几种药物需要滴定至推荐剂量，同时监测不常见但危险的药物 副作用。鉴于治疗的复杂性和心脏病专家数量不足来管理这一问题 由于患者人数众多，非医生开始标准化用药和调整药物剂量已经成为可能 已作为患者联合护理团队 (PACT) 当前初级护理实践的辅助手段进行了测试。药剂师 已发现药物起始和药物滴定可以改善多种疾病的推荐护理 随机试验。然而，很少有 VA 机构实施了药物启动和药物滴定 PACT 药剂师针对 HF 的治疗。假设：药物治疗的开始和心衰药物的滴定可以 在 VA Palo Alto HCS 的两个地点成功实施，并将增加三个地点的推荐使用 患有心衰的退伍军人的药物课程。弥补差距（知识和实践）。国家高频 仪表板可用于跟踪指南推荐的治疗，并显示许多患者没有接受治疗 最佳高频汽车 e．创新。使用 PACT 药剂师为心力衰竭提供规范化护理将释放更多时间 这项工作使初级保健提供者能够增加获得初级保健的机会。鉴于患者是 通常请 VA 心脏病学来完成此任务，药剂师管理也可以改善 VA 的获取 心脏病学。具体目标 1) 在 PACT 中实施药剂师主导的协议化护理，以启动和实施 两类初级保健机构的心力衰竭药物滴定。 2) 确定促进因素、障碍、忠诚度和成本 的实施。 3) 展示对推荐的心衰护理和增加 VA 初级服务的影响 PACT 药剂师管理带来的护理和 VA 心脏病学。我们合作的项目方法 与 VA Palo Alto HCS 的药房和 PACT 领导一起使用 PACT 药剂师 HF 药物 一家 CBOC（加利福尼亚州蒙特雷）的管理部门。在这个项目中，我们将把这种做法推广到两种类型的网站： VA 位于帕洛阿尔托医疗中心的初级保健诊所（大型）和加利福尼亚州 VA 圣何塞 CBOC（小型）。 实施策略 作为拟议项目的一部分，我们（VISN CMO Godbout 博士的合作伙伴） 和 QUERI 团队）将 1）组织当地冠军，2）促进传播到两个地点，3）提供 向 PACT 药房和初级保健领导层进行审核和反馈。我们将汇聚本地冠军 （VA 药房、VA 初级保健和 VA 心脏病学领导层）将随着时间的推移显示结果，并将 提供有关如何修改其站点实施的建议。为了便于实施，我们将制定 并提供包括药房药物管理协议的操作手册和工具包。 评估 我们的评估将检查实施情况（例如保真度、障碍、促进因素、成本、提供者 满意度、员工敬业度）和结果（符合指南推荐护理的患者比例， 使用权）。主要结果/终点的描述。实施成果将包括 每个 PACT 团队每月由药剂师管理的心力衰竭患者数量以及药物数量 每个 PACT 团队每月由 PACT 药剂师进行的更改。药剂师和主要提供者满意度 并将确定扩大药剂师角色所带来的感知负担。实施成本将为 确定并与效益（增加访问、提高护理指标质量）进行比较，以提供 商业案例分析和投资回报。护理结果将是使用 VA 推荐的五种 HF 国家 VA HF 仪表板的药物类别、PACT 和 VA 心脏病学的访问/等待时间 预约、入院、再入院、死亡率、急诊科就诊和药物不良反应。