Watchful Waiting as a Strategy for Reducing Low-value Spinal Imaging

项目摘要 过度使用越来越多地被视为病人安全的框架内。在初级保健中，患者 急性腰痛患者经常需要诊断性成像，初级保健医生（PCP）认为 压力，默许这种要求，以维持病人的信任和满意度。脊柱成像在 急性下腰痛会带来假阳性结果的诊断评价、患者标签和 焦虑和不必要的治疗（包括脊柱手术）以及潜在的下游并发症。 观察等待建议已被发现是减少低价值治疗的有效策略（例如， 小儿耳部感染），一些证据表明，观察等待的方法是可以接受的， 很多病人要求检查。与此同时，心理学理论（调节契合与非契合）表明， 可以定制医生的信息，以扩大患者对警惕等待策略的接受度。 为了响应机构医疗保健质量和研究的兴趣，在推进模拟研究 为了提高患者的安全性，我们建议使用标准化的模拟干预方法来改进和评估一种新的模拟干预方法。 患者（SP）-或扮演患者角色的演员-教导PCP支持观察等待方法 当病人要求低价值的脊柱成像腰痛。具体目标是： 目的1：使用一线PCP和基层医疗焦点小组的关键信息访谈 患者完善理论知情的标准化基于患者的干预，旨在教授 实践PCP如何建议在患者要求低价值脊柱成像时观察等待， 下背痛 目的2：测试标准化患者指导员（SPI）提供的PCP培训的有效性 在随机临床试验中观察等待的应用。 我们假设干预将：a）降低实际患者中低价值脊柱成像的发生率， 干预后PCP观察到的急性背痛患者（根据RCT前的发生率进行调整）; B）PCP增加 建议在随访期间对以前未见过的SP进行观察等待; c）增加PCP自我- 报告的使用和有效性，建议观察等待实际腰痛患者;和d）没有 对患者对医生的实际信任和满意度产生不利影响。 目的3：评估干预效果是否推广到其他高成本、低价值的项目 成像测试。 我们假设SP干预将：a）降低晚期颈部成像的发生率， 随访期间研究PCP观察到的颈部疼痛的实际患者（根据基线发生率调整）， 和B）增加PCP自我报告的使用和建议观察等待而不是成像的有效性 颈部疼痛和其他肌肉骨骼疼痛的患者。

PROJECT SUMMARY Overutilization is increasingly viewed within the framework of patient safety. In primary care, patients with acute low back pain frequently request diagnostic imaging, and primary care physicians (PCPs) feel pressure to acquiesce to such requests to sustain patient trust and satisfaction. Spinal imaging in patients with acute low back pain poses risks from diagnostic evaluation of false-positive findings, patient labeling and anxiety, and unnecessary treatment (including spinal surgery) with potential downstream complications. Watchful waiting advice has been found an effective strategy to reduce low-value treatment (e.g., pediatric ear infections), and some evidence suggests a watchful waiting approach would be acceptable to many patients requesting tests. Meanwhile, psychological theory (regulatory fit vs. non-fit) suggests that physician messages could be tailored to magnify patient acceptance of a watchful waiting strategy. In response to the Agency Healthcare Quality and Research's interest in advancing simulation research to improve patient safety, we propose to refine and evaluate a novel simulated intervention using standardized patients (SPs) -- or actors playing the roles of patients – to teach PCPs to endorse a watchful waiting approach when patients request low-value spinal imaging for low back pain. Specific aims are: Aim 1: To use key informant interviews of front-line PCPs and focus groups with primary care patients to refine a theory-informed standardized patient-based intervention designed to teach practicing PCPs how to advise watchful waiting when patients request low-value spinal imaging for low back pain. Aim 2: To test the effectiveness of standardized patient instructor (SPI)-delivered PCP training in the use of watchful waiting in a randomized clinical trial. We hypothesize that the intervention will: a) reduce rates of low-value spinal imaging among actual patients with acute back pain seen by PCPs post-intervention (adjusting for pre-RCT rates); b) increase PCP advice to pursue watchful waiting during a followup visit with a previously unseen SP; c) increase PCP self- reported use and efficacy of advising watchful waiting with actual low back pain patients; and d) have no adverse impact on actual patient trust and satisfaction with physicians. Aim 3: To assess whether the intervention effects generalize to other high-cost, low-value imaging tests. We hypothesize that the SP intervention will: a) decrease rates of advanced neck imaging among actual patients with neck pain seen by study PCPs during the follow-up period (adjusting for baseline rates), and b) increase PCP self-reported use and efficacy of advising watchful waiting rather than imaging for patients with neck pain and other musculoskeletal pain.