Optimizing Delivery of Evidence-Based COPD Care for Rural Veterans

About This Grant

Background: Chronic obstructive pulmonary disease (COPD), the sixth leading cause of death in the U.S., disproportionately affects Veterans, who are twice as likely to suffer from COPD as the general US population. Compared with urban counties, rural counties have higher rates of COPD-related hospitalizations and deaths. Challenges in accessing evidence-based care are likely contributing factors to worse rural COPD outcomes. Implementation of evidence-based COPD care through a pharmacist-led COPD program can improve access to and delivery of high-value care for rural Veterans. However, it is unclear if this type of implementation strategy for COPD is feasible, acceptable, appropriate, and effective for Veterans in resource-constrained rural clinics where pulmonary subspecialty care is not readily accessible. Significance/Impact: Rural Veterans are disproportionately affected by COPD. Additionally, they are less likely to receive evidence-based COPD care. This proposal will improve Veteran health by providing better quality and more equitable access to evidence-based COPD care. This work will advance delivery of high- value care to Veterans who face challenges in accessing care and will reduce health disparities by leveraging effective implementation strategies. Innovation: Innovations include: 1) extending the use of pharmacist-led CDM programs to include COPD tailored for rural Veterans; 2) testing a “proactive” (without prompting from patients or clinicians) program in which rural patients with frequent COPD exacerbations will be systematically identified outside of a routine clinic visit; and 3) targeting prevention of COPD exacerbations and hospitalizations. Specific Aims: The proposed research and training plan will increase my skills in implementation research, specifically focusing on rapid qualitative and mixed methods research, intervention development, and implementation evaluation through the following aims: Aim 1. Identify patient and institutional barriers and facilitators to implementation of a proactive pharmacist-led COPD program for rural Veterans; Aim 2. Pilot a proactive pharmacist-led COPD program to optimize COPD care for rural Veterans. Pharmacists will optimize COPD care for Veterans in rural clinics who are at high risk for hospitalization (n=40 patients). Program core components will include: 1) COPD education, 2) medication optimization, 3) inhaler technique review, and 4) smoking cessation; Aim 3. Development of an implementation toolkit to support implementation of a pharmacist-led COPD program for rural clinics. Methodology: The first research aims will be conducting qualitative assessments of patient and institutional (Aim 1) barriers to and facilitators for implementation of a proactive pharmacist-led COPD program by performing semi-structured interviews of rural COPD patients (n=30), rural clinic staff (n=20), and leadership (n=10) in VISN 23. Aim 2 will be to pilot a proactive pharmacist-led COPD program to optimize COPD care in rural clinics targeting Veterans (n=40) at highest risk for COPD hospitalizations. The study pharmacists will optimize COPD management based on established COPD guidelines. Aim 3 will use existing COPD programs to develop a prototype of an implementation toolkit support implementation of the proactive, pharmacist-led COPD program for rural clinics. Survey and focus groups will evaluate the toolkit. Next Steps/Implementation: After generating key pilot data, we will perform a large-scale hybrid effectiveness-implementation study of pharmacist-led COPD management.