Strategies to Reduce Unnecessary Noninvasive Imaging

背景：患者接受数百万次非侵入性诊断性成像检查，包括计算机 断层扫描，磁共振成像，核医学，在美国每年。基于 根据专业医学协会制定的适当使用标准（AUC），这些测试中有20-30%可能是 不适当的，即，潜在的获益风险比没有最大化。关于适当性的数据有限 退伍军人健康管理局（VHA）内部的成像表明，不适当的使用类似于 在VHA外面。已经采用了各种方法来鼓励更适当地使用非侵入性 显像其中最受欢迎的是电子决策支持工具（DST）。这些软件产品是 添加到患者护理工作流程中，以捕获有意义的AUC数据并减少不必要的测试。最近的一 VHA证据综合方案（ESP）报告得出结论，对实施 DST及其使用可能产生的负面影响。此外，VHA的非侵入性成像的成本 需要进行尚未计算的测试，以确定不适当测试的负担。 具体目标：在本次评选过程中，我们将实现以下具体目标：（1）评估潜力 成功采用DST的障碍和促进因素，（2）使用 分步实施过程，（3）通过以下方式估计DST在VA卫生系统中的财政有效性： 开发一个微成本模型，用于提供非侵入性成像测试。 意义：通过这些调查，我们将收集有关如何调整流程的宝贵见解， 改善数百万项昂贵测试的排序。如果能有效减少不必要的测试， 该提案将最终改善退伍军人获得护理的机会，并降低辐射风险。 创新：对DST的研究主要集中在有效性上，很少关注 实施过程和可能的不利影响，如供应商的不满和效率低下。我们 这些调查将为研究地区测试的这些方面开辟新天地。使用定性和微观- 我们建议的成本计算方法是创新的，因为它们在临床研究中没有得到充分利用。 方法：我们将应用实用稳健实施和可持续性模型（PRISM）， 理论领域框架（TDF）的具体目标，为这个奖项。在具体目标1中，我们将使用 定性和定量的方法，以确定可能的障碍和促进DST的实施， 对订购非侵入性测试的供应商进行访谈和调查。在具体目标2中，实施DST 对于非侵入性成像，将从检测率、不适当检测的比例 和提供者的反馈。首先，对AUC不知情的提供者将订购 像往常一样测试。第二，在订购时，他们将立即收到关于 测试，并被给予更改顺序的选项。第三，如果供应商的决定不符合 AUC，供应商将被要求提供测试订单的理由。这些步骤将帮助我们了解 （c）为数据集服务组的实施进程提供支持，并解决最近的ESP提出的文献中的空白。 具体目标3，非侵入性成像检查的费用将使用行政部门提供的信息计算。 数据库，护理交付的时间和运动观察，以及退伍军人的成本日记。 预期成果：我们预期通过这些调查，我们将学习并能够分享 关于实施DST进行无创成像的重要经验教训。这些结果将作为 研究者发起了研究赠款，以进一步推广退伍军人事务部系统内的DST，并适应其他 成像/测试模态，如超声心动图。

Background: Patients undergo millions of noninvasive diagnostic imaging tests, including computed tomography, magnetic resonance imaging, and nuclear medicine, in the United States annually. Based on Appropriate Use Criteria (AUC) developed by professional medical societies, 20-30% of these tests may be inappropriate, i.e., the potential benefit-to-risk ratio is not maximized. Limited data on appropriateness of imaging within the Veterans Health Administration (VHA) suggests that inappropriate use is similar to that outside the VHA. A variety of methods have been employed to encourage more appropriate use of noninvasive imaging. One of the most popular is an electronic decision support tool (DST). These software products are added to patient care workflows to capture meaningful AUC data and reduce unnecessary testing. A recent VHA Evidence Synthesis Program (ESP) report concluded that little is known about the implementation of DSTs and possible negative ramifications of their use. Further, the cost to the VHA of noninvasive imaging testing, which has not been calculated, is needed to determine the burden of inappropriate tests. Specific Aims: In the course of this award, we will achieve the following specific aims: (1) assess potential barriers and facilitators to successful adoption of a DST, (2) determine the effectiveness of a DST using a stepped implementation process, and (3) estimate the fiscal effectiveness of a DST in the VA health system by developing a micro-costing model for delivery of noninvasive imaging tests. Significance: Through these investigations, we will glean valuable insight into how to adjust processes to improve the ordering of millions of costly tests. If effective at reducing unnecessary tests, the results from this proposal will ultimately improve Veterans' access to care and reduce radiation risks. Innovation: Study of DSTs has focused primarily on effectiveness, with little attention paid to the implementation process and possible adverse effects such as provider dissatisfaction and inefficiency. Our investigations will break new ground in studying these aspects of DSTs. The use of qualitative and micro- costing methods as we propose is innovative given their underuse for clinically oriented research. Methods: We will apply the Practical Robust Implementation and Sustainability Model (PRISM) and Theoretical Domains Framework (TDF) to the specific aims for this award. In Specific Aim 1, we will use qualitative and quantitative methods to identify possible barriers and facilitators to DST implementation through interviews and surveys of providers who order noninvasive tests. In Specific Aim 2, implementation of a DST for noninvasive imaging will be assessed from the rate of testing, the proportion of testing that is inappropriate, and feedback from providers in three discrete steps. First, providers blinded to AUC for imaging tests will order tests as usual. Second, at the point of ordering, they will receive immediate feedback on appropriateness of the test and be given the option to change the order. Third, if the provider's decision is not consistent with AUC, the provider will be required to give a justification for the test order. These steps will help us understand the implementation process for DSTs and to address gaps in the literature raised by the recent ESP. In Specific Aim 3, the cost of noninvasive imaging tests will be calculated using information from administrative databases, time-and-motion observation of care delivery, and cost diaries from Veterans. Expected Results: We anticipate that through these investigations, we will learn and be able to share important lessons about implementation of a DST for noninvasive imaging. The results will be the basis for investigator initiated research grants on further spread of DSTs within the VA system and adaptation to other imaging/testing modalities such as echocardiography.