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VA中的常见状况，具有高发病率和死亡率。 因此，HF住院和死亡率是VA安全分析的重点 （帆）。此外，HF治疗很复杂，因为现在已知四类药物已知 独立延长生存，建议一起使用（非裔美国人五个）。 几种药物需要滴定才能推荐剂量，同时监测不常见但危险的剂量 副作用。鉴于治疗的复杂性以及心脏病专家数量不足 大量的患者人群，非物理学家对药物的标准化药物启动和滴定 被视为当前患者对齐护理团队（PACT）的初级护理实践的辅助工作。药剂师 已经发现药物启动和药物滴定可以改善多种推荐的护理 随机试验。但是，很少有VA站点实施药物启动和药物滴定 适用于公约药剂师的HF。假设：HF药物的药房药物启动和滴定可以 在VA Palo Alto HCS的两个地点成功实施，并将增加建议使用三个 HF退伍军人的药物课程。解决的差距（知识和实践）。国家HF 仪表板可用于跟踪指南建议的治疗，并表明许多患者未接受 最佳HF汽车e。创新。使用PACT药剂师为HF提供协议的护理将释放 这项工作的初级保健提供者使他们能够增加获得初级保健的机会。鉴于患者是 通常是在此任务中引用VA心脏病学，药剂师管理还可以改善对VA的访问 心脏病学。具体目的1）实施药剂师在启动协议中领导的协议护理和 在两种类型的初级保健站点上滴定HF药物。 2）确定促进者，障碍，忠诚度和成本 实施。 3）对推荐的HF护理产生了影响，并增加了对VA Primar的访问 PACT药剂师管理，护理和VA心脏病学。我们合作的项目方法 在VA Palo Alto HCS的药房和PACT领导力中，他们使用PACT药剂师HF药物 一个CBOC（加利福尼亚州蒙特雷）的管理。在这个项目中，我们将把这种做法传播到两种类型的站点：VA 总部位于帕洛阿尔托医学中心的初级保健诊所（大型）和VA San Jose CBOC，CA（小）。 实施策略作为拟议项目的一部分（Visn CMO Godbout博士的合作伙伴关系 Queri团队）将1）组织当地冠军，2）促进分配到两个地点，3）提供 审核和反馈对PACT药房和初级保健领导。我们将汇集当地冠军 （VA Pharmacy，VA初级保健和VA心脏病学领导）将随着时间的流逝而显示结果，并将 提供有关如何修改其网站实现的建议。为了促进实施，我们将发展 并提供包括药房管理协议在内的操作手册和工具包。 评估我们的评估将检查实施（例如，富裕，障碍，障碍，促进者，成本，提供商 满意度，员工敬业度）和结果（符合指南的患者的一部分建议护理， 使用权）。主要结果/终点的描述。实施结果将包括 每个协定团队每月由药剂师管理的HF患者人数和药物数量 每个协定团队每月每月的药剂师进行的更改。药剂师和主要提供商满意度 并将确定具有扩大的药剂师角色负担。实施费用将是 确定并与福利（增加访问，增加的护理指标质量）进行比较，以提供 业务案例分析和投资回报率。护理结果将使用五个va推荐的HF 来自国家VA HF仪表板的药物课程，访问/等待时间和VA心脏病学 约会，录取，再入院，死亡率，急诊科和不良药物反应。