De-Implementation of Low Value Imaging in Pulmonary Embolism (DELVE PE)

1项目概要 2美国每年1.2亿次急诊（艾德）就诊中有2%（2%）接受了计算机辅助检查。 每年3次肺动脉造影（CTPA）检查肺栓塞（PE）。然而，其中许多是 4可避免的不必要的检查使患者承受额外的费用、电离辐射和造影剂过敏反应的风险 5媒体。此外，由于假阳性CTPA是常见的（估计为5-26%），过度诊断和过度治疗是常见的。 美国的6大问题尽管指南建议减少PE的低价值成像， 7美国ED中不必要的PE影像学检查数量持续增加，使患者暴露于过度检查的伤害， 8过度诊断先前的战略试图缩小这一知识-实践质量差距，但只取得了一定的成功， 9可能是因为改变供应商的行为是具有挑战性的，大多数计划都集中在孤立的战略上。我们提出 10.制定、试行和评估一项多层面的“增强型”反馈战略， 11例PE成像。选择核心策略-反馈，以针对以下发现的PE中低价值成像的驱动因素： 第12章我们的基础工作：知识、同伴压力、情绪和对后果的信念。我们设计的策略是 13一种新的反馈理论，临床表现反馈干预理论（CP-FIT）。反馈反馈是 14.通过补充战略“加强”，以协助行动规划，并使临床医生能够改变他们的行为。这 15包括适当测试的辅助工具，通过明确的算法指导临床医生评估PE， 16个教育播客和当地冠军。在目标1中，我们将制定、完善和实施“去执行” 17个战略组成部分。我们将对反馈报告的原型进行认知测试， 18电子健康记录（EHR）-综合援助，记录教育播客，并确定和培训当地冠军。在 19.目的2：我们会在5个急症室试行其他版本的强化适应机制策略，以评估其可接受性和适当性。我们 20将改变反馈组成部分的交付（当地冠军与部门主席），教育播客（与 21或没有真实的患者叙述），以及用于适当测试的辅助设备（静态与EHR集成辅助设备），以确定 22这些迭代的可接受性、适当性和附加值。我们将试行不同版本的战略来评估 CP-FIT的23个方面，包括复杂性，社会影响力和可操作性，CP-FIT建议驱动反馈 第24章最后的改变我们将使用混合方法来评估策略，并选择一个改进的策略， 25多中心试验。在这份K23申请中，我们提出了详细的职业发展计划， 26先进的实施科学策略，方法和试验设计的方法和技术专业知识。我很 由经验丰富的导师和顾问团队提供支持。在这个指导职业发展奖结束时，我将 28名患者具有强大的药物衍生和理论指导策略，并将在多中心测试该策略 第29章作为一个独立的调查员 30

1 PROJECT SUMMARY 2 Two percent (2%) of all 120 million annual emergency department (ED) visits in the United States undergo computed 3 tomographic pulmonary angiography (CTPA) for pulmonary embolism (PE) every year. However, many of these are 4 avoidable. Unnecessary testing subjects patients to additional costs, ionizing radiation, and risk of anaphylaxis from contrast 5 media. Further, because false positive CTPAs are common (estimated at 5-26%), overdiagnosis and overtreatment are 6 growing problems in the United States. Despite guidelines recommending the reduction of low-value imaging for PE, the 7 volume of unnecessary imaging studies for PE in US EDs continues to rise, exposing patients to harm from overtesting and 8 overdiagnosis. Prior strategies have attempted to close this knowledge-practice quality gap but only had modest success, 9 possibly because changing provider behavior is challenging and most initiatives focused on isolated strategies. We propose 10 to develop, pilot, and evaluate a multi-dimensional `enhanced' audit-feedback strategy (EAF) to de-implement low-value 11 imaging in PE. The core strategy, audit-feedback, was chosen to target drivers of low-value imaging in PE discovered in 12 our foundational work: knowledge, peer pressure, emotion, and belief about consequences. We designed the strategy using 13 a novel audit-feedback theory, the Clinical Performance Feedback Intervention Theory (CP-FIT). The audit-feedback is 14 `enhanced' by complementary strategies to assist in action planning and empower clinicians to change their behavior. This 15 includes an aid for appropriate testing that guides clinicians through an unambiguous algorithm for evaluation of PE, an 16 educational podcast, and local champions. In Aim 1, we will develop, refine, and operationalize the de-implementation 17 strategy components. We will conduct cognitive testing of the prototypes of the audit-feedback reports, develop an 18 electronic health record (EHR)-integrated aid, record the educational podcast, and identify and train local champions. In 19 Aim 2, we will pilot alternative versions of the EAF strategy in 5 EDs to evaluate acceptability and appropriateness. We 20 will alter the delivery of the components of feedback (local champion versus departmental chair), educational podcast (with 21 or without a real patient narrative), and the aid for appropriate testing (static versus EHR-integrated aid) to ascertain the 22 acceptability, appropriateness, and added value of these iterations. We will pilot different versions of the strategy to evaluate 23 aspects of CP-FIT including complexity, social influence, and actionability, which CP-FIT suggests drive the audit-feedback 24 cycle and, ultimately, behavior change. We will use mixed methods to evaluate the strategy and select a refined strategy for 25 a multi-center trial. In this K23 application, we have proposed a detailed career development plan in which I will gain 26 methodological and technical expertise in advanced implementation science strategies, methods, and trial design. I am well 27 supported by an experienced team of mentors and advisors. At the end of this mentored career development award, I will 28 have a robust empirically-derived and theory-informed strategy and will be positioned to test this strategy in a multi-center 29 trial as an independent investigator. 30