VA Greater Los Angeles Healthcare System and UCLA National Clinician Scholars Program, Los Angeles, California, USA
Center for the Study of Healthcare Innovation, Implementation and Policy and Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.
BMJ Open Qual. 2022 Jul;11(3). doi: 10.1136/bmjoq-2022-001901.
To address ambulatory care sensitive hospitalisations in heart failure (HF), we implemented a quality improvement initiative to reduce admissions and improve guideline-directed medical therapy (GDMT) prescription, through proactive integration of remote patient monitoring-home telehealth (RPM-HT) and pharmacist consultations. Each enrolled patient (n=38) was assigned an RPM-HT registered nurse (RN), cardiology licensed independent provider (provider), and, if referred, a clinical pharmacy specialist (pharmacist). The RN called patients weekly and for changes detected by RPM-HT, while the pharmacist worked to optimise GDMT. The RN and pharmacist communicated clinical status changes to the provider for expedited management. Process measures were the percentage of outbound RN weekly calls missed per enrolled patient; the weekly percentage of provider interventions missed; and the number of initiative-driven diuretic changes. Outcome measures included eligible GDMT medications prescribed, optimisation of those medications, and the pre-post difference in emergency department (ED) visits/hospitalisations. After a 4-week run-in period, RN weekly calls missed per enrolled patient decreased from a mean of 21.4% (weeks 5-15) to 10.2% (weeks 16-23). Weekly missed provider interventions decreased from a mean of 15.1% (weeks 1-15) to 3.4% (weeks 16-23), with special cause variation detected. The initiative resulted in 43 diuretic changes in 21 patients. Among 34 active patients, 65 ED visits (0.16 per person-month) occurred in 12 months pre intervention compared with 8 ED visits (0.04 per person-month) for 6 intervention months (p<0.001). Among 16 patients referred to pharmacist, the per cent of eligible GDMT medications prescribed increased by 17.1% (p<0.001); the number of patients receiving all eligible medications increased from 3 to 11 (p=0.008). Similarly, the per cent optimisation of GDMT doses increased by 25.3% (p<0.001), with the number of patients maximally optimised on GDMT increasing from 1 to 6 (p=0.06). We concluded that a cardiology, RPM-HT RN and pharmacist team improved prescription of GDMT and may have reduced HF admissions.
为了解决心力衰竭（HF）门诊护理敏感的住院问题，我们实施了一项质量改进计划，通过积极整合远程患者监测-家庭远程医疗（RPM-HT）和药剂师咨询，以减少住院人数并改善指南指导的药物治疗（GDMT）处方。每位入组患者（n=38）都分配了一名 RPM-HT 注册护士（RN）、心脏病学持照独立提供者（provider），如果需要，还分配了一名临床药剂师专家（pharmacist）。RN 每周给患者打电话，并根据 RPM-HT 检测到的变化进行电话联系，而药剂师则努力优化 GDMT。RN 和药剂师会将临床状况变化告知 provider，以便进行快速管理。过程指标是每个入组患者每周错过的 RN 外拨电话的百分比；每周错过 provider 干预的百分比；以及计划驱动的利尿剂变化数量。结果指标包括开具合格的 GDMT 药物、优化这些药物，以及急诊就诊（ED）/住院前后的差异。经过 4 周的试行期，每个入组患者每周错过的 RN 电话从第 5-15 周的平均 21.4%下降到第 16-23 周的 10.2%。每周错过 provider 干预的次数从第 1-15 周的平均 15.1%下降到第 16-23 周的 3.4%，检测到特殊原因的变化。该计划导致 21 名患者中的 43 种利尿剂发生变化。在 34 名活跃患者中，干预前 12 个月有 65 次 ED 就诊（0.16 人/月），而干预 6 个月期间有 8 次 ED 就诊（0.04 人/月）（p<0.001）。在转诊给药剂师的 16 名患者中，开具合格 GDMT 药物的百分比增加了 17.1%（p<0.001）；接受所有合格药物的患者人数从 3 人增加到 11 人（p=0.008）。同样，GDMT 剂量优化的百分比增加了 25.3%（p<0.001），同时接受 GDMT 最大优化的患者人数从 1 人增加到 6 人（p=0.06）。我们得出结论，心脏病学、RPM-HT RN 和药剂师团队改善了 GDMT 的处方，可能减少了 HF 住院人数。
