Development of a Metric to Detect and Decrease Low-Value Prescribing in Older Adults.
Development of a Metric to Detect and Decrease Low-Value Prescribing in Older Adults.
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DOI：
10.1001/jamanetworkopen.2021.48599
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发表时间：
2022-02-01
影响因子：
13.8
通讯作者：
Gellad WF
中科院分区：
文献类型：
--
作者：
Radomski TR;Decker A;Khodyakov D;Thorpe CT;Hanlon JT;Roberts MS;Fine MJ;Gellad WF
这项定性研究描述了与临床医生，取消处方专家，医疗保健领导者和其他利益相关者组成的小组建立EVOLV-Rx（评估减少低价值处方的机会）的过程。是否可以使用常见形式的医疗保健数据开发一个可扩展和广泛适用的指标，以检测老年人中的低价值处方？在这项对27种低价值处方做法的定性研究中，使用在线改良德尔菲法召集了一个专家小组，以制定科学有效和临床有用的低价值处方指标。该小组确定了18种最突出的低价值处方做法，并将其作为最终指标的组成部分。这项研究中开发的指标可以提高低价值处方实践的检测，减少多药，并使老年人能够获得高价值的护理。在常见形式的医疗保健数据（如行政索赔或电子健康记录）中检测低价值护理的方法主要集中在测试和程序上，而不是药物，这代表了系统测量低价值处方能力的重大差距。开发一个可扩展和广泛适用的指标，其中包含一组质量指标（EVOLV-Rx），用于医疗保健数据，以检测和减少老年人中的低价值处方，并了解不同利益相关者的观点。这项定性研究采用了在线改进德尔菲法，召集了一个由15名医生和药剂师组成的专家小组。该小组由临床医生，卫生系统领导者和研究人员组成，其任务是对来自药物安全标准的候选低价值处方实践进行评级和讨论;同行评议文献;以及患者，护理人员和医生观点的定性研究。兰德公司的ExpertLens在线平台被用来开展小组活动。小组成员于二零二一年一月一日至三月三十一日期间参与三轮。小组成员使用9分Likert量表进行评分，然后讨论检测低价值处方实践的标准的科学有效性和临床有用性。候选低价值处方实践的评级如下：1 - 3，表明低有效性或有用性; 3.5 - 6，不确定的有效性或有用性;和6.5 - 9，高有效性或有用性。使用兰德公司/加州大学洛杉矶分校（加州大学，洛杉矶）适当方法评估小组成员之间的一致性以及科学有效性和临床有用性的程度。在确定的527个低价值处方建议中，考虑将27个离散候选低价值处方实践纳入EVOLV-Rx。在第一轮之后，18个候选实践被专家组评为具有高科学有效性和临床有用性（得分≥6.5）。经过第二轮小组审议，修订了检测19种候选做法的标准。在第三轮之后，18个候选实践符合入选标准，在科学有效性和临床有用性方面的最终中位数得分为6.5或更高。在未纳入最终版本EVOLV-Rx的实践中，3项获得了高科学有效性（评分≥6.5）但临床有效性（评分<6.5）评级，而6项获得了不确定的科学有效性评级（评分<6.5）。这项研究最终导致了EVOLV-Rx的开发，并涉及一个专家小组，他们确定了老年人护理中18种最突出的低价值处方实践。应用EVOLV-Rx可以加强对低价值处方做法的检测，减少多种药物，并使老年人能够在全方位的卫生服务中获得高价值的护理。
This qualitative study describes the process of building EVOLV-Rx (Evaluating Opportunities to Decrease Low-Value Prescribing) with a panel of clinicians, deprescribing experts, health care leaders, and other stakeholders. Can a scalable and broadly applicable metric be developed using common forms of health care data to detect low-value prescribing among older adults? In this qualitative study of 27 low-value prescribing practices, a panel of experts was convened using an online modified-Delphi approach to develop a scientifically valid and clinically useful low-value prescribing metric. This panel identified the 18 most salient low-value prescribing practices, which were included as a component of the final metric. The metric developed in this study may enhance the detection of low-value prescribing practices, reduce polypharmacy, and enable older adults to receive high-value care. Metrics that detect low-value care in common forms of health care data, such as administrative claims or electronic health records, primarily focus on tests and procedures but not on medications, representing a major gap in the ability to systematically measure low-value prescribing. To develop a scalable and broadly applicable metric that contains a set of quality indicators (EVOLV-Rx) for use in health care data to detect and reduce low-value prescribing among older adults and that is informed by diverse stakeholders’ perspectives. This qualitative study used an online modified-Delphi method to convene an expert panel of 15 physicians and pharmacists. This panel, comprising clinicians, health system leaders, and researchers, was tasked with rating and discussing candidate low-value prescribing practices that were derived from medication safety criteria; peer-reviewed literature; and qualitative studies of patient, caregiver, and physician perspectives. The RAND ExpertLens online platform was used to conduct the activities of the panel. The panelists were engaged for 3 rounds between January 1 and March 31, 2021. Panelists used a 9-point Likert scale to rate and then discuss the scientific validity and clinical usefulness of the criteria to detect low-value prescribing practices. Candidate low-value prescribing practices were rated as follows: 1 to 3, indicating low validity or usefulness; 3.5 to 6, uncertain validity or usefulness; and 6.5 to 9, high validity or usefulness. Agreement among panelists and the degree of scientific validity and clinical usefulness were assessed using the RAND/UCLA (University of California, Los Angeles) Appropriateness Method. Of the 527 low-value prescribing recommendations identified, 27 discrete candidate low-value prescribing practices were considered for inclusion in EVOLV-Rx. After round 1, 18 candidate practices were rated by the panel as having high scientific validity and clinical usefulness (scores of ≥6.5). After round 2 panel deliberations, the criteria to detect 19 candidate practices were revised. After round 3, 18 candidate practices met the inclusion criteria, receiving final median scores of 6.5 or higher for both scientific validity and clinical usefulness. Of those practices that were not included in the final version of EVOLV-Rx, 3 received high scientific validity (scores ≥6.5) but uncertain clinical usefulness (scores <6.5) ratings, whereas 6 received uncertain scientific validity rating (scores <6.5). This study culminated in the development of EVOLV-Rx and involved a panel of experts who identified the 18 most salient low-value prescribing practices in the care of older adults. Applying EVOLV-Rx may enhance the detection of low-value prescribing practices, reduce polypharmacy, and enable older adults to receive high-value care across the full spectrum of health services.
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