Improving safety and quality through evidence-based de-implementation of ineffective diagnostics and therapeutics.

通过基于证据的无效诊断和治疗的取消实施来提高安全性和质量。

• 批准号: 10295784
• 负责人: David H Au
• 金额: --
• 依托单位: VA PUGET SOUND HEALTHCARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2015
• 资助国家: 美国
• 起止时间: 2015-10-01 至 2020-09-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10295784
• 关键词: Address; Adrenal Cortex Hormones; Antipsychotic Agents; Behavioral; Cardiac; Cardiology; Caring; Chronic Obstructive Airway Disease; Clinic; Clinical; Deimplementation; Dementia; Diagnostic; Disease; Effectiveness; Etiology; Evaluation; Follow-Up Studies; Funding; Goals; Guidelines; Health Services Accessibility; Healthcare; Image; Improve Access; Inhalation; Investments; Knowledge; Long-Term Care; Lung nodule; Methods; Modeling; Myocardial perfusion; Patients; Perception; Pharmaceutical Preparations; Pneumonia; Policies; Procedures; Provider; Quality of Care; Radiation exposure; Recommendation; Resources; Risk; Safety; Science; Series; Services; Societies; Steroids; Stroke; Structure; Taxonomy; Testing; Therapeutic; Time; Veterans; Wait Time; Work; X-Ray Computed Tomography; base; budget impact; burnout; care delivery; care systems; clinical Diagnosis; clinical practice; compare effectiveness; effectiveness testing; evidence base; follow-up; formative assessment; health care delivery; implementation science; implementation strategy; improved; ineffective therapies; medical specialties; mortality risk; patient oriented; patient population; perfusion imaging; pharmacy benefit; programs; tool

 DESCRIPTION (provided by applicant): Project Background: According to IOM, high quality care is safe, effective and patient centered. Initiatives such as Choosing Wisely, a program to de-implement low value practices, can provide an effective message to simultaneously improve quality and value. However, while Choosing Wisely identifies targets for de-implementation, it does not speak to what strategies may help achieve this goal. While much is known about effective implementation strategies, little is known about effective de-implementation strategies. This is important because active de- implementation likely entails different dynamics, and unintended consequences, than implementation. VA operational partners in Pharmacy Benefits Management and Office of Specialty Care Services have helped identify and prioritize an initial set of common clinical practices that should be de-implemented. Project Objectives: Our overall goal is to improve healthcare delivery, safety and value for Veterans and VHA, consistent with multiple strategies outlined in the VA Blueprint for Excellence, by working with our partners in the Office of Specialty Care and Pharmacy Benefits Management to de-implement low value practices. We propose a series of experimental and quasi-experimental quality-improvement projects that compare the effectiveness of alternative de-implementation strategies: strategies based on changing clinician information and knowledge, and strategies based on providing tools and substitutes to the harmful practices. Our specific aims are to: Aim 1. Work with key operational leaders to identify and prioritize diagnostics and therapeutics that are ineffective, contraindicated, or of low value to patients, and develop de-implementation strategies that work in concert with operational strategies and policies. Aim 2. Test the effectiveness of de-implementation strategies to reduce ineffective, contraindicated or low value diagnostics and therapeutics. Aim 3. Develop the science and taxonomy of de-implementation by assessing the impact on de- implementation from (a) clinicians' perception of the evidence about ineffective practices, (b) clinicians' professional efficacy, and (c) clinics' organizational context. Aim 4. Assess the budget impact of de-implementation strategies in order to inform dissemination. Project Methods: We will test de-implementation strategies for four clinical practices spanning multiple specialties and patient populations, including both therapeutic and diagnostic practices. In each project, we will test the effectiveness of de-implementation strategies alone and in combination, and will assess the budget impact of fielding de- implementation strategies. Built on the structure of our successful and longstanding QUERI/Office of Specialty Care Evaluation Center, we will incorporate a mixed-methods formative evaluation to assess barriers and facilitators, and identify potential unintended consequences of the de-implementation strategies. We will assess changes, before and after employing de-implementation strategies in participating clinicians' perceptions of the empirical evidence against the ineffective practice; clinicians' intent to reduce the ineffective practice; and professional inefficacy (a component of work-related burnout). We will also assess key components of organizational context, such as culture of change among leaders and staff. We will assess organizational context as a moderator of de-implementation strategy effectiveness across clinical settings and practice changes. By doing this we will contribute to the science and taxonomy of de-implementation by developing, testing and refining a conceptual model of de-implementation.

 描述（由申请人提供）： 项目背景：IOM认为，高质量的护理是安全、有效和以患者为中心的。诸如明智选择这样的举措，一个取消低价值做法的计划，可以提供一个有效的信息，同时提高质量和价值。然而，尽管《明智选择》确定了取消执行的目标，但它并没有说明什么战略可能有助于实现这一目标。虽然人们对有效的执行战略了解很多，但对有效的取消执行战略却知之甚少。这一点很重要，因为积极的去执行可能会带来与执行不同的动态和意外后果。药房福利管理和专业护理服务办公室的VA运营合作伙伴帮助确定并优先考虑了一套应取消实施的初始常见临床实践。项目目标：我们的总体目标是改善退伍军人和VHA的医疗保健服务，安全性和价值，与VA卓越蓝图中概述的多项战略一致，通过与我们在专科护理和药房福利管理办公室的合作伙伴合作，取消实施低价值做法。我们提出了一系列的实验和准实验的质量改进项目，比较替代去执行策略的有效性：基于改变临床医生的信息和知识的战略，并提供工具和替代品的有害做法的基础上的战略。我们的具体目标是：目标1。与关键运营领导者合作，识别并优先考虑无效、禁忌或对患者价值低的诊断和治疗，并制定与运营战略和政策一致的去执行战略。目标二。测试取消实施战略的有效性，以减少无效，禁忌或低价值的诊断和治疗。目标3。通过评估以下方面对取消实施的影响，发展取消实施的科学和分类：（a）临床医生对无效实践证据的看法，（B）临床医生的专业效能，以及（c）诊所的组织背景。目标4。评估取消执行战略的预算影响，以便为宣传提供信息。项目方法：我们将测试跨多个专业和患者人群，包括治疗和诊断实践的四个临床实践的去实现策略。在每一个项目中，我们将测试取消执行战略单独和结合使用的有效性，并将评估实施取消执行战略对预算的影响。建立在我们成功和长期的QUERI/专科护理评估中心办公室的结构上，我们将采用混合方法进行形成性评估，以评估障碍和促进因素，并确定取消实施策略的潜在意外后果。我们将评估的变化，之前和之后，在参与临床医生的经验证据对无效的做法的看法，临床医生的意图，以减少无效的做法，和专业无效（工作相关的倦怠的一个组成部分）。我们还将评估组织环境的关键组成部分，例如领导者和工作人员之间的变革文化。我们将评估组织背景作为临床环境和实践变化中取消实施策略有效性的调节剂。通过这样做，我们将通过开发、测试和完善一个去执行的概念模型，为去执行的科学和分类学做出贡献。