The Development, Validation, and Application of a Claims-based Metric of Low Value Prescribing in Older Adults

摘要 过度使用低价值的卫生服务（即，直接或下游成本或 危害超过其好处）是美国浪费医疗保健支出的主要驱动力。现有低- 价值健康服务指标包括测试和程序，但不包括药物。因此，低价值预- 没有系统地研究划线。迫切需要准确地描述和减少 年龄≥65岁的成人中的低价值处方，因为2/5的患者处方了≥5种药物（即，多角体 Macy），导致不良药物事件、不必要的自付费用和住院治疗。的选择 Wisely Campaign已经发布了反对一些低价值处方做法的建议。然而，在这方面， 这些建议尚未在行政数据中实施，而是与以下方面一起制定的： 把病人对医疗价值的看法结合起来。因此，没有一个指标可以巩固和 简化现有建议，并纳入患者、处方医生和付款人的观点 明确定义并系统衡量低价值处方。一个基于索赔的指标， 不同利益相关者的投入将使卫生系统和支付者能够轻松衡量低价值处方， 老年人，制定政策和干预措施，以减少这种处方，而不影响质量， 患者满意度。这个指导职业发展奖的总体目标是发展，价值- 日期，并应用一个指标，将准确地表征特定的低价值处方做法，使用管理， 参考性数据，反映患者、处方医生和付款人的观点和信念，因为它们与 保健价值。为了达到这个目标，我们将完成以下具体目标：1）识别和消除- 从不同利益相关者的角度出发，将精细的关键低价值处方做法纳入低价值处方， 价值处方指标; 2）验证低价值处方指标的组成部分，以供管理员使用， 3）确定与低价值处方药相关的患者、提供者和地理因素， ing.这些目标的完成将提供关于以下方面的关键证据： 和处方者参与低价值处方的激励措施，并将赋予卫生系统，支付者， 政策制定者进一步研究并以临床合理和可接受的方式减少此类处方， 患者和处方者。为了完成我的训练，我需要在定性研究方面的额外训练，phar- 宏观流行病学，以及卫生服务干预措施的设计和实施。这将使我能够 成功竞争NIH R系列赠款，以领导评估低价值处方对 以病人为中心的结果，并试点和实施卫生服务干预，以减轻低价值的前， 在老年人中使用所提出的度量进行划线。我将通过K23获得的技能和经验 奖项将使我成为一个独立的临床研究员，致力于进一步的使命， 通过确保老年人在全方位的卫生服务中获得高价值的护理，来实现国家保险计划。

ABSTRACT The overuse of low-value health services (i.e., a health service whose immediate or downstream costs or harms exceed its benefits) is a major driver of wasteful healthcare spending in the United States. Existing low- value health service metrics have incorporated tests and procedures, but not medications. Thus, low-value pre- scribing has not been systematically studied. There is an urgent need to accurately characterize and reduce low-value prescribing in adults aged ≥65 years, as 2 in 5 have been prescribed ≥5 medications (i.e., polyphar- macy), resulting in adverse drug events, unnecessary out-of-pocket costs, and hospitalizations. The Choosing Wisely Campaign has published recommendations against some low-value prescribing practices. However, these recommendations have not been operationalized for use in administrative data and were developed with- out incorporating patients’ perspectives on healthcare value. Thus, there is no metric that consolidates and streamlines existing recommendations and incorporates the perspectives of patients, prescribers, and payers to clearly define and systematically measure low-value prescribing. A claims-based metric that incorporates the input of diverse stakeholders will enable health systems and payers to easily measure low-value prescribing in older adults and develop policies and interventions to reduce such prescribing without compromising quality or patient satisfaction. The overarching objective of this mentored career development award is to develop, vali- date, and apply a metric that will accurately characterize specific low-value prescribing practices using admin- istrative data and reflect the perspectives and beliefs of patients, prescribers, and payers as they relate to healthcare value. To achieve this objective, we will complete the following Specific Aims: 1) To identify and de- fine key low-value prescribing practices from the perspective of diverse stakeholders to incorporate in the low- value prescribing metric; 2) To validate the components of the low-value prescribing metric for use in adminis- trative data; 3) To determine the patient, provider, and geographic factors associated with low-value prescrib- ing. Completion of these Aims will provide key evidence regarding the prevalence of, factors associated with, and prescribers incentives to engage in low-value prescribing, and will empower health systems, payers, and policy makers to further study and reduce such prescribing in a way that is clinically sound and acceptable to patients and prescribers. To complete my training, I require additional training in qualitative research, phar- macoepidemiology, and the design and implementation of health service interventions. This will enable me to successfully compete for NIH R-series grants to lead studies evaluating the impact of low-value prescribing on patient-centered outcomes and to pilot and implement a health service intervention to mitigate low-value pre- scribing in older adults using the proposed metric. The skills and experience I will obtain through this K23 Award will enable me to become an independent clinician-investigator, committed to furthering the mission of the NIA by ensuring that older adults receive high-value care across the full spectrum of health services.