Practice Variation

练习变化

• 批准号: 8020756
• 负责人: GREGORY G SIMON
• 金额: $ 7.67万
• 依托单位: KAISER FOUNDATION HEALTH PLAN OF WASHINGTON
• 依托单位国家: 美国
• 财政年份: 2010
• 资助国家: 美国
• 起止时间: 2010-09-24 至 2013-07-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8020756
• 关键词: Address; Adoption; Age; Ambulatory Care; Ambulatory Care Facilities; Antidepressive Agents; Back; Bipolar Disorder; Budgets; Caring; Characteristics; Clinical; Comorbidity; Complex; Data; Diagnosis; Education; Ethnic Origin; Ethnic group; Formularies; Frequencies; Future; Geographic Locations; Geographic state; Growth; Health; Health Benefit; Health Care Costs; Health Planning; Health Services; Health Services Research; Health system; Healthcare; Hip Fractures; Hospitalization; Hospitals; Information Systems; Insurance Coverage; Medical; Medication Management; Mental Health; Mood Disorders; Motivation; Observational Study; Operative Surgical Procedures; Outcome; Patient Preferences; Patients; Pattern; Pharmaceutical Preparations; Policies; Procedures; Provider; Psychotherapy; Quality of Care; Race; Recording of previous events; Reporting; Research; Resources; Role; Sampling; Sampling Studies; Services; Severity of illness; Statistical Methods; Unipolar Depression; Variant; alternative treatment; comparative effectiveness; computerized; copayment; cost; cost effectiveness; effective therapy; effectiveness research; ethnic difference; experience; follow-up; geographic difference; improved; interest; preference; programs; sex

Health services research demonstrating unexplained variation in use of more expensive health services has been a primary motivation for studying the comparative effectiveness of alternative treatments (1, 2). For example, the Congressional Budget Office report that argued for a greater federal role in comparative effectiveness research cited markedly greater geographic variation in hospitalization for back surgery (a more elective procedure) than in hospitalization for hip fracture (a non-elective procedure) (2). The limited practice variation research in mental health has also demonstrated significant variation between geographic areas or provider groups in rates of hospital care, outpatient services, and use of specific medications (3-6). Some ofthis variation has been associated with differences in patients' demographic characteristics and in supply of providers or facilifies. These limited data suggest that practice variation in mental health care is as much a concern as is variation in use of medical or surgical treatments. We identify two issues not adequately addressed by previous research regarding health care practice variation. First, previous studies have lacked the multi-level data necessary to disentangle how patient, provider, and health system characteristics are related to variation in treatment choices and subsequent health services costs. Differences between outpatient clinics in adoption of a new medication might represent differences in the patients served, differences in providers' preferences or pracfice styles, or health system factors (such as formulary policies or medication management programs). Second, identifying variation in service use does not determine whether higher or lower rates are more desirable. As discussed below, identifying providers or facilities with higher rates for a particular treatment has very different implications depending on whether that treatment improves health outcomes or simply increases costs. Variation in care is of interest in terms of both quality of care and restraining the growth of health care costs. In the case of health services demonstrated to improve health outcomes (high-value services), significant variation in care suggests potential under-ufilizafion of effective treatments. In such cases, we would hope that variations in treatment choices would be explained either by differences in clinical need (severity of illness, prior treatment experience, co-occurring conditions, etc) or by differences in patients' preferences. Ideally, use of effective treatments would be only minimally infiuenced by non-clinical factors such as providers' preferences or patients' insurance coverage. For example, variation between racial or ethnic groups in receipt of effective or high-value services might be appropriate if that variation refiected racial or ethnic differences in patients' treatment preferences. But racial or ethnic variation in receipt of high-value treatments would not be appropriate if it instead refiected providers' biases. In the case of health services that increase costs without demonstrated clinical benefit (low-value services) significant variation in care suggests potential over-use of services and an opportunity to decrease costs without sacrificing health outcomes. We might hope that use of low-value services is more infiuenced by cost-reduction efforts (differential copayments, formulary restrictions, organizational initiatives). And if we observe significant variation among providers in use of low-value services, this suggests an opportunity for additional education or quality improvement efforts to increase the efficiency of care. Eariy adoption of a new treatment has quite different implications for quality improvement and policy depending on whether that treatment improves outcomes or simply increases costs. Because previous research on practice variation has not typically distinguished between these two scenarios, we know little about whether rates of use for high- and low-value treatments tend to vary together between providers, facilities, or geographic areas - or whether high- and low-value services show distinct patterns.

卫生服务研究表明，在使用更昂贵的卫生服务的原因不明的变化一直是研究替代治疗的比较有效性的主要动机（1，2）。例如，国会预算办公室的报告主张在比较有效性研究中发挥更大的联邦作用，并引用了背部手术（一种更具选择性的手术）住院的地理差异明显大于髋部骨折（一种非选择性手术）住院的地理差异[2]。 精神健康方面的有限实践差异研究也表明，地理区域或提供者群体之间在医院护理，门诊服务和特定药物使用率方面存在显着差异（3-6）。这种变化的一部分与患者的人口统计学特征和提供者或设施的供应差异有关。这些有限的数据表明，精神卫生保健的实践变化与使用药物或手术治疗的变化一样令人担忧。 我们确定了两个问题没有充分解决以前的研究有关医疗保健实践的变化。首先，以前的研究缺乏必要的多层次的数据来理清患者，提供者和卫生系统的特点是如何与治疗选择和随后的卫生服务成本的变化。门诊诊所之间采用新药的差异可能代表所服务的患者的差异，提供者偏好或实践风格或卫生系统的差异 因素（如处方药政策或药物管理计划）。其次，识别服务使用的变化并不能确定更高还是更低的费率更可取。如下文所述，确定某一特定治疗费率较高的提供者或设施，其影响大不相同，这取决于该治疗是改善健康结果还是仅仅增加费用。 护理的变化是感兴趣的护理质量和限制医疗保健费用的增长。在已证明可改善健康结果的保健服务（高价值服务）方面，护理方面的显著差异表明有效治疗可能不足。在这种情况下，我们希望治疗选择的差异可以通过临床需求的差异（疾病的严重程度，既往治疗经验，合并症等）或患者偏好的差异来解释。理想情况下，非临床因素对有效治疗的影响最小 例如提供者的偏好或患者的保险范围。例如，如果种族或族裔群体在接受有效或高价值服务方面的差异反映了患者治疗偏好的种族或族裔差异，则这种差异可能是适当的。但是，如果种族或民族差异反映了提供者的偏见，那么接受高价值治疗的种族或民族差异就不合适了。在医疗服务增加成本而没有证明临床效益的情况下（低价值服务），护理的显著差异表明可能过度使用服务，并有机会在不牺牲健康结果的情况下降低成本。我们可能希望，低价值服务的使用更多地受到降低成本的影响（不同的共同负担，处方限制，组织倡议）。如果我们观察到提供者在使用低价值服务方面存在显著差异，这表明有机会进行额外的教育或质量改进工作，以提高护理效率。早期采用一种新的治疗方法对质量改善和政策有着相当不同的影响，这取决于该治疗方法是改善了结果还是仅仅增加了成本。 由于以前的研究实践差异通常没有区分这两种情况下，我们知道很少的使用率为高价值和低价值的治疗往往会有所不同的供应商之间，设施，或地理区域-或是否高价值和低价值的服务显示出不同的模式。