Assessing Treatment Delay and Resource Use to Improve Value of Pre-Surgical Care

以情节为基础(“捆绑”)的方法已被推广用于绩效衡量，以鼓励 在所有参与的提供者中分担对医疗保健提供的质量和效率的责任 病人的护理。大多数基于剧集的试播节目使用相对较窄的剧集定义，典型的 突发事件在住院或手术时开始。然而，很少有人注意到 衡量术前护理的质量和价值。虽然住院和术后护理费用很高， 就诊和支出方面，门诊服务占医疗资源利用率最高。 在手术前的这段时间，患者经常与医疗保健系统进行多次接触，这是一个 这是确定改善退伍军人护理协调和质量的机会的重要时机。 作为这项CDA的一部分，拟议的研究将促进创新战略的发展，以改善 对患有腕管综合征(CTS)的退伍军人的协调、接触和护理价值，特别是在 手术期。CTS的治疗是开发护理质量和护理质量测量模型的理想环境 初级保健提供者和专科提供者之间的利用率，因为每年约有40,000名退伍军人 新近被诊断出患有CTS，并经常从初级保健的一个或多个提供者那里接受护理， 职业治疗、矫形外科、整形外科、神经外科、物理医学和康复， 或者疼痛管理。尽管在某些临床情况下，各种非手术治疗可能是合适的 在这种情况下，如果这些相同的治疗导致患者的延迟，那么这些治疗的价值可能会很低 从手术中。这一系列研究旨在评估和提高CTS术前护理的质量和利用率，将 更广泛地促进对如何优化以患者为中心的外科护理协调的理解。这 该项目将有三个目标： 目标1：使用VHA国家数据，CTS术前价值的设施水平差异将通过以下方式进行评估 检查质量/访问(不适当的手术延迟)和资源利用(手术前的数量 )，同时评估关键结构和过程变量的影响，包括将 社区提供者。 目标2：将对患者和临床医生进行半结构化访谈，以进一步识别和更好地 了解与手术前病历质量和利用率相关的因素。临床医生和患者将 从手术前表现最好的2家机构和最差的2家机构招聘 评估视角、偏好、组织因素和护理目标的措施(质量和利用率) 影响手术前CTS各阶段决策的关键利益相关者(患者和提供者) 关心。 目标3：目标1和目标2的结果将用于设计和试验多学科CTS临床护理 解决影响术前事件质量/访问的系统性障碍和流程的途径 初级保健和专科诊所提供的CTS相关护理的利用情况。试点测试将评估 干预措施的可行性、可接受性和改善设施水平手术前事件价值的潜力 为预期的随机试验做准备。 这些针对CTS改进的方法将在未来的工作中应用，以检查质量和利用率的变化 其他情况下的术前护理，目的是优化卫生保健服务的使用并最大限度地 接受外科治疗的退伍军人的结局。在期待更多退伍军人进入社区的情况下- 这一倡议还将有利于监测和更好地协调 在不同的医疗保健环境中提供护理。

Episode-based (“bundled”) approaches have been promoted for performance measurement to encourage shared accountability for the quality and efficiency of healthcare delivery among all of the providers involved in a patient's care. Most episode-based pilot programs use relatively narrow episode definitions, with the typical episode trigger starting at the time of a hospitalization or surgery. However, little attention has been paid to measuring quality and value of pre-surgical care. Although inpatient and postoperative care are costly, outpatient care accounts for the greatest utilization of health care resources in terms of visits and expenditures. This pre-surgical period, during which patients often have multiple touches with the healthcare system, is an important time to identify opportunities to improve coordination and quality of care for Veterans. The studies proposed as part of this CDA will facilitate development of innovative strategies to improve coordination, access, and value of care for Veterans with carpal tunnel syndrome (CTS), particularly in the pre- surgical period. Treatment for CTS is an ideal context to develop measurement models of care quality and utilization between primary care and specialty providers, given that approximately 40,000 Veterans per year are newly diagnosed with CTS and often receive care from one or more providers from primary care, occupational therapy, orthopedic surgery, plastic surgery, neurosurgery, physical medicine and rehabilitation, or pain management. Although a variety of nonoperative treatments can be appropriate under certain clinical circumstances, these same treatments can be low value if they lead to delays for patients who would benefit from surgery. This series of studies to evaluate and improve quality and utilization of CTS pre-surgical care will advance an understanding of how to optimize coordination of patient-centered surgical care more broadly. This project will have 3 aims: Aim 1: Using VHA national data, facility-level variation in CTS pre-surgical value will be assessed by examining both quality/access (inappropriate delay of surgery) and resource utilization (number of pre-surgical encounters), while evaluating the impact of key structural and process variables, including referral to community providers. Aim 2: Semi-structured interviews with patients and clinicians will be conducted to further identify and better understand factors associated with pre-surgical episode quality and utilization. Clinicians and patients will be recruited from 2 facilities with the highest and 2 facilities with the lowest performance on both pre-surgical measures (quality and utilization) to evaluate perspectives, preferences, organizational factors, and care goals of key stakeholders (patients and providers) who impact decision-making across phases of pre-surgical CTS care. Aim 3: Findings from Aim 1 and Aim 2 will be used to design and pilot a multi-disciplinary CTS clinical care pathway that addresses systemic barriers and processes impacting pre-surgical episode quality/access and utilization of CTS-related care provided across primary care and specialty clinics. Pilot testing will assess the intervention's feasibility, acceptability, and potential to improve facility-level pre-surgical episode value in preparation for an anticipated randomized trial. These methods, refined for CTS, will be applied in future work to examine variation in quality and utilization of pre-surgical care for other conditions, with the goal of optimizing use of health care services and maximizing outcomes for Veterans who receive surgical care. In anticipation of greater Veteran access to community- based care, this initiative will also be beneficial for monitoring and better coordinating the quality and value of care across diverse healthcare settings.