A top-five list for emergency medicine: a pilot project to improve the value of emergency care.
A top-five list for emergency medicine: a pilot project to improve the value of emergency care.
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急诊医学五强榜单：提升急诊价值的试点项目
DOI：
10.1001/jamainternmed.2013.12688
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发表时间：
2014
影响因子：
39
通讯作者：
A. Venkatesh
中科院分区：
文献类型：
--
作者：
J. Schuur;D. Carney;E. Lyn;A. Raja;J. Michael;N. G. Ross;A. Venkatesh
美国的平均医疗费用正在以不可持续的速度增长;从2003年到2011年，急诊科（艾德）的费用上涨了240%，从560美元上涨到1354美元。急诊医生要求的诊断测试、治疗和住院治疗导致了巨大的成本。目的建立一个“前五名”的测试，治疗和处置决策，是没有价值的，是服从标准化，并可由急诊医学临床医生采取行动的名单。设计、设置和参与者：改良的德尔菲共识过程和对6个急诊科的283名急诊临床医生（医生、医师助理和执业护士）的调查。干预我们组建了一个技术专家小组（TEP），并进行了修改后的德尔菲过程，以确定一个前五名的名单，使用4个步骤的过程。在第一阶段，我们通过TEP头脑风暴和临床医生的电子邮件征集生成了一个低价值临床决策列表。在第2阶段，TEP根据成本贡献、患者获益和临床医生的可操作性对项目进行排名。在第3阶段，我们调查了6个ED的所有订购临床医生，了解每个项目的不同方面。在第四阶段，TEP根据调查结果和讨论投票选出最终的前五名名单。主要结果和措施急诊医学前五名名单。TEP根据对成本的贡献、对患者的益处和临床医生的可操作性对项目进行排名。该调查要求临床医生对每个项目的潜在益处或对患者的危害以及提供者的可操作性进行评分。投票和调查使用5点李克特量表。使用Pearson域间相关性。结果第一阶段确定了64个低价值项目。第2阶段将该列表缩小至第3阶段调查中包括的7项实验室检查、3项药物治疗、4项影像学研究和3项处置决定（应答率为71.0%）。所有17个项目均显示获益与可操作性之间存在显著正相关（r，0.19-0.37 [P ≤ .01]）。1个项目获得了TEP的一致支持，4个项目获得了多数支持，12个项目获得了至少1票。结论和相关性我们的TEP确定了价值较低且在艾德医疗保健提供者控制范围内的临床行动。该方法可用于确定急诊医学中过度使用的其他可操作目标。
IMPORTANCE The mean cost of medical care in the United States is growing at an unsustainable rate; from 2003 through 2011, the cost for an emergency department (ED) visit rose 240%, from $560 to $1354. The diagnostic tests, treatments, and hospitalizations that emergency clinicians order result in significant costs. OBJECTIVE To create a "top-five" list of tests, treatments, and disposition decisions that are of little value, are amenable to standardization, and are actionable by emergency medicine clinicians. DESIGN, SETTING, AND PARTICIPANTS Modified Delphi consensus process and survey of 283 emergency medicine clinicians (physicians, physician assistants, and nurse practitioners) from 6 EDs. INTERVENTION We assembled a technical expert panel (TEP) and conducted a modified Delphi process to identify a top-five list using a 4-step process. In phase 1, we generated a list of low-value clinical decisions from TEP brainstorming and e-mail solicitation of clinicians. In phase 2, the TEP ranked items on contribution to cost, benefit to patients, and actionability by clinicians. In phase 3, we surveyed all ordering clinicians from the 6 EDs regarding distinct aspects of each item. In phase 4, the TEP voted for a final top-five list based on survey results and discussion. MAIN OUTCOMES AND MEASURES A top-five list for emergency medicine. The TEP ranked items on contribution to cost, benefit to patients, and actionability by clinicians. The survey asked clinicians to score items on the potential benefit or harm to patients and the provider actionability of each item. Voting and surveys used 5-point Likert scales. A Pearson interdomain correlation was used. RESULTS Phase 1 identified 64 low-value items. Phase 2 narrowed this list to 7 laboratory tests, 3 medications, 4 imaging studies, and 3 disposition decisions included in the phase 3 survey (71.0% response rate). All 17 items showed a significant positive correlation between benefit and actionability (r, 0.19-0.37 [P ≤ .01]). One item received unanimous TEP support, 4 received majority support, and 12 received at least 1 vote. CONCLUSIONS AND RELEVANCE Our TEP identified clinical actions that are of low value and within the control of ED health care providers. This method can be used to identify additional actionable targets of overuse in emergency medicine.