The Development, Validation, and Application of a Claims-based Metric of Low Value Prescribing in Older Adults

摘要 过度使用低价值的保健服务(即，其直接或下游费用或 弊大于利)是美国医疗支出浪费性的主要驱动因素。现有的低- 价值医疗服务指标纳入了测试和程序，但没有纳入药物。因此，低价值的Pre- 划线还没有被系统地研究过。迫切需要准确地描述和减少 在65岁的成年人中开低价值处方，因为每5个人中就有2个人开过≥5药物(即，多聚酚-5)。 导致不良药物事件、不必要的自付费用和住院治疗。选择 Wisely Campaign发布了针对一些低价值处方做法的建议。然而， 这些建议尚未付诸实施，无法在行政数据中使用，而是与以下各方共同制定的： 纳入患者对医疗保健价值的看法。因此，没有任何指标可以整合和 简化现有建议，并纳入患者、处方者和付款人的观点 明确界定和系统衡量低值处方。一个基于声明的指标，它结合了 不同利益相关者的投入将使卫生系统和支付者能够轻松地衡量 并制定政策和干预措施，以减少此类处方而不影响质量或 病人满意度。这个指导职业发展奖的首要目标是发展，瓦利- 日期，并应用一个指标，该指标将使用管理-准确描述特定的低价值处方做法- 指导性数据，并反映患者、处方者和付款人的观点和信念 医疗保健价值。为了达到这一目标，我们将完成以下具体目标：1)识别和消除- 从不同利益相关者的角度出发，将精品低价处方做法纳入低价 值规定指标；2)验证用于管理的低值规定指标的组成部分- 传统数据；3)确定与低价值处方相关的患者、提供者和地理因素- 英。这些目标的完成将提供关于以下方面的关键证据： 和处方者激励参与低价值处方，并将增强卫生系统、支付者和 政策制定者进一步研究并以临床上合理并可接受的方式减少此类处方 病人和处方者。为了完成我的培训，我需要在定性研究方面的额外培训，Phar- 宏观流行病学，以及卫生服务干预措施的设计和实施。这将使我能够 成功竞争NIH R系列拨款，领导评估低价值处方对 以患者为中心的结果，并试点和实施卫生服务干预，以缓解低价值的预 使用建议的度量标准在老年人中进行划线。我将通过K23获得的技能和经验 获奖将使我成为一名独立的临床医生和研究员，致力于推动 NIA通过确保老年人在整个医疗服务范围内获得高价值的护理来实现这一目标。

ABSTRACT The overuse of low-value health services (i.e., a health service whose immediate or downstream costs or harms exceed its benefits) is a major driver of wasteful healthcare spending in the United States. Existing low- value health service metrics have incorporated tests and procedures, but not medications. Thus, low-value pre- scribing has not been systematically studied. There is an urgent need to accurately characterize and reduce low-value prescribing in adults aged ≥65 years, as 2 in 5 have been prescribed ≥5 medications (i.e., polyphar- macy), resulting in adverse drug events, unnecessary out-of-pocket costs, and hospitalizations. The Choosing Wisely Campaign has published recommendations against some low-value prescribing practices. However, these recommendations have not been operationalized for use in administrative data and were developed with- out incorporating patients’ perspectives on healthcare value. Thus, there is no metric that consolidates and streamlines existing recommendations and incorporates the perspectives of patients, prescribers, and payers to clearly define and systematically measure low-value prescribing. A claims-based metric that incorporates the input of diverse stakeholders will enable health systems and payers to easily measure low-value prescribing in older adults and develop policies and interventions to reduce such prescribing without compromising quality or patient satisfaction. The overarching objective of this mentored career development award is to develop, vali- date, and apply a metric that will accurately characterize specific low-value prescribing practices using admin- istrative data and reflect the perspectives and beliefs of patients, prescribers, and payers as they relate to healthcare value. To achieve this objective, we will complete the following Specific Aims: 1) To identify and de- fine key low-value prescribing practices from the perspective of diverse stakeholders to incorporate in the low- value prescribing metric; 2) To validate the components of the low-value prescribing metric for use in adminis- trative data; 3) To determine the patient, provider, and geographic factors associated with low-value prescrib- ing. Completion of these Aims will provide key evidence regarding the prevalence of, factors associated with, and prescribers incentives to engage in low-value prescribing, and will empower health systems, payers, and policy makers to further study and reduce such prescribing in a way that is clinically sound and acceptable to patients and prescribers. To complete my training, I require additional training in qualitative research, phar- macoepidemiology, and the design and implementation of health service interventions. This will enable me to successfully compete for NIH R-series grants to lead studies evaluating the impact of low-value prescribing on patient-centered outcomes and to pilot and implement a health service intervention to mitigate low-value pre- scribing in older adults using the proposed metric. The skills and experience I will obtain through this K23 Award will enable me to become an independent clinician-investigator, committed to furthering the mission of the NIA by ensuring that older adults receive high-value care across the full spectrum of health services.