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

项目总结 过度使用越来越多地被视为患者安全框架内的问题。在初级保健中，患者 急性下腰痛经常需要诊断成像，初级保健医生(PCP)感到 为了维持患者的信任和满意度而默许这类请求的压力。颈椎病患者的脊柱影像检查 急性下腰痛带来的风险来自对假阳性结果的诊断评估，患者标签和 焦虑和不必要的治疗(包括脊柱手术)和潜在的下游并发症。 警惕的等待建议已经被发现是减少低价值治疗的有效策略(例如， 儿童耳部感染)，一些证据表明，警惕的等待方法将是可以接受的 许多病人要求做检查。同时，心理学理论(调节匹配与不匹配)表明 医生的信息可以被定制，以扩大患者对警惕等待策略的接受度。 回应机构医疗质量和研究对推进模拟研究的兴趣 为了提高患者的安全性，我们建议改进和评估一种新的模拟干预措施，使用标准化的 患者(SP)--或扮演患者角色的演员--教PCP支持警惕的等待方法 当患者要求低价值的脊柱成像来治疗下腰痛时。具体目标是： 目标1：利用对一线初级保健医生和焦点群体的关键线人访谈 患者提炼理论知情的标准化患者干预措施，旨在传授 练习PCP当患者要求低价值的脊柱成像时如何建议警惕等待 腰背痛。 目的2：测试标准化患者指导员(SPI)提供的PCP培训的有效性 在一项随机临床试验中使用观察等待。 我们假设，干预措施将：a)降低实际人群中低价值脊柱成像的比率 急性背痛的患者在干预后进行PCP检查(根据RCT前的比率进行调整)；b)增加PCP 建议在对以前未见过的SP进行后续访问期间保持警惕等待；c)增加PCP自我 对实际的下腰痛患者建议警惕等待的用法和效果；以及d)没有 对患者对医生的实际信任和满意度的不利影响。 目标3：评估干预效果是否推广到其他高成本、低价值 成像测试。 我们假设SP干预将：a)在以下人群中降低晚期颈部显像率 研究PCP在随访期内看到的实际颈部疼痛患者(调整基线比率)， 以及b)增加五氯苯酚的自我报告使用情况和建议警惕等待而不是成像的有效性 有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.