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

摘要 过度使用低价值卫生服务（即直接或下游成本或 弊大于利）是美国医疗保健支出浪费的主要驱动因素。现有低 价值健康服务指标包含了测试和程序，但没有包含药物。因此，低价值预 刻画尚未得到系统研究。迫切需要准确表征和减少 年龄 ≥ 65 岁的成年人的处方价值较低，因为五分之二的人服用了 ≥ 5 种药物（即多药） 梅西百货），导致药物不良事件、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， 这些建议尚未用于行政数据，而是根据以下内容制定的： 纳入患者对医疗保健价值的看法。因此，没有任何衡量标准可以整合和 简化现有建议并纳入患者、处方者和付款人的观点 明确定义并系统地衡量低价值处方。基于索赔的指标，其中包含 不同利益相关者的投入将使卫生系统和付款人能够轻松衡量低价值处方 老年人并制定政策和干预措施，以在不影响质量或质量的情况下减少此类处方 患者满意度。这个指导性职业发展奖的总体目标是发展、验证 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实践 统计数据并反映患者、处方者和付款人的观点和信念 医疗保健价值。为了实现这一目标，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细化关键的低价值处方实践，将其纳入低价值 价值规定指标； 2) 验证用于管理的低值处方指标的组成部分 统计数据； 3) 确定与低价值处方相关的患者、提供者和地理因素 ing。完成这些目标将提供有关以下因素的流行程度的关键证据： 和处方者参与低价值处方的激励措施，并将赋予卫生系统、支付者和 政策制定者应进一步研究并以临床上合理且可接受的方式减少此类处方 患者和处方者。为了完成我的培训，我需要在定性研究、制药方面进行额外的培训 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，以领导评估低价值处方对患者影响的研究 以患者为中心的结果，并试点和实施卫生服务干预措施，以减轻低价值的预 使用建议的指标在老年人中进行书写。我将通过这个K23获得的技能和经验 该奖项将使我成为一名独立的临床研究者，致力于推进以下使命： NIA 确保老年人在全方位的卫生服务中获得高价值护理。

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.