Leveraging implementation and behavioral science to reduce harmful overuse of diagnostic testing in critically ill children

项目摘要 过度治疗--收益不超过风险的医疗保健--占高达2000亿美元 每年在美国，并与更糟糕的结果和死亡有关。不必要地使用诊断程序 检测是过度治疗的主要驱动因素。 诊断和治疗疑似败血症就是这一挑战的例证。在住院的儿童中，严重的败血症 常见(8.2%的患病率)和致命性(25%的死亡率)。儿科医院优先考虑脓毒症的早期识别 以及快速给药作为关键的业绩衡量标准。儿童败血症的体征和症状， 然而，都是非特定的。由此产生的诊断不确定性可能会导致有害的过度治疗。 血培养是诊断菌血症所致败血症的金标准。通常，临床医生会采集血液 同时开始使用经验性的广谱抗生素。只有5%-15%的培养是阳性的， 然而，其中高达50%的人实际上是假阳性。假阳性结果导致不必要的 抗生素、更长的住院时间和更高的成本。减少儿科不必要的血培养 重症监护病房患者是可行和安全的，但目前血液培养的实践模式差异很大， 而培养法的使用可能是由反射行为和对错过败血症的恐惧推动的。 在我的主要导师的帮助下，我一直在领导一个由AHRQ资助的14个PICU血液培养质量改进项目 自2017年起，协作名为Bright STAR(R18 HS025642-01)。我现在将利用Bright Star来实现1) 调查是什么导致了PICU中血培养的过度使用，以及2)开发和测试安全地减少 血培养过度使用。我将使用执行研究综合框架，即 认知偏差，以及实现这些目标的Proctor实现框架，在一系列 定性、定量和准实验研究调查。 这项提议将给我以下方面的经验：应用实施/行为科学的框架，进行 混合方法研究，设计实施策略，并进行临床试验。这些技能是 对实现我的长期目标至关重要：设计和测试安全地减少有害的过度使用 对危重儿童进行的其他不必要的诊断测试(以及由此产生的不必要的治疗)。我 将由一支资金雄厚、在传染病方面有专长的成功研究人员团队指导， 实施科学、行为科学、试验设计和混合方法研究。我会得到全力支持 费城儿童医院和宾夕法尼亚大学重症监护科， 访问无数资源(如宾夕法尼亚大学实施科学中心、儿科中心 临床有效性研究和宾夕法尼亚大学混合方法实验室)来帮助我实现我的目标。这就做 利用该奖项成为独立的实施科学家，通过减少 对危重儿童大规模过度使用不必要的检查是有害的。

Project Abstract Overtreatment – health care in which the benefit does not outweigh risks – accounts for up to $200 billion annually in the United States, and is associated with worse outcomes and death. Unnecessary use of diagnostic testing is a primary driver of overtreatment. Diagnosing and treating suspected sepsis exemplifies this challenge. In hospitalized children, severe sepsis is common (8.2% prevalence) and deadly (25% mortality rate). Pediatric hospitals prioritize early sepsis recognition and rapid antibiotic administration as key performance metrics. Signs and symptoms of sepsis in children, however, are non-specific. The resulting diagnostic uncertainty may lead to harmful overtreatment. Blood cultures are the gold standard for diagnosing sepsis due to bacteremia. Frequently, clinicians obtain blood cultures and simultaneously start empiric broad-spectrum antibiotics. Only 5-15% of cultures will be positive, however, and up to 50% of those are actually falsely positive. False positive results lead to unnecessary antibiotics, increased lengths of stay, and increased costs. Reduction in unnecessary blood cultures in pediatric intensive care unit patients is feasible and safe, but current practice patterns for blood culture use vary widely, and culture use may be driven by reflexive behavior and fear of missing sepsis. With my Primary Mentor, I have been leading an AHRQ-funded 14-site PICU blood culture quality improvement collaborative called Bright STAR (R18 HS025642-01) since 2017. I will now leverage Bright STAR to 1) investigate what leads to blood culture overuse in the PICU, and 2) develop and test strategies to safely reduce blood culture overuse. I will use the Consolidated Framework for Implementation Research, the concept of cognitive bias, and the Proctor implementation framework to accomplish these objectives, in a series of qualitative, quantitative, and quasi-experimental research investigations. This proposal will give me experience in: applying frameworks of implementation/behavioral science, conducting mixed methods studies, designing implementation strategies, and conducting a clinical trial. These skills are critical to achieving my long term goal: to design and test strategies to safely reduce harmful overuse of other unnecessary diagnostic tests (and consequently, unnecessary treatments) in critically ill children. I will be mentored by a team of highly funded, successful researchers with expertise in infectious diseases, implementation science, behavioral science, trial design, and mixed methods research. I will have the full support of the Division of Critical Care at The Children's Hospital of Philadelphia and the University of Pennsylvania, with access to innumerable resources (such as the Penn Implementation Science Center, the Center for Pediatric Clinical Effectiveness research, and the Penn Mixed-Methods Laboratory) to help me accomplish my aims. I will use this award to become an independent implementation scientist improving patient outcomes by reducing harmful overuse of unnecessary tests in critically ill children on a large scale.