Assessing Treatment Delay and Resource Use to Improve Value of Pre-Surgical Care

已推广基于事件（“捆绑”）的方法进行绩效衡量，以鼓励 在所有参与的提供者之间对医疗服务的质量和效率承担共同责任， 病人的护理。大多数基于剧集的试点节目使用相对狭窄的剧集定义，典型的 在住院或手术时开始发作触发。然而，很少有人注意到 衡量术前护理的质量和价值。虽然住院和术后护理费用昂贵， 就就诊次数和支出而言，门诊服务占卫生保健资源的最大利用率。 在此期间，患者经常与医疗保健系统进行多次接触， 这是确定改善退伍军人护理协调和质量的机会的重要时机。 作为本综合发展分析的一部分，建议进行的研究将有助于制定创新战略， 协调，访问，护理退伍军人与腕管综合征（CTS）的价值，特别是在前 手术期间。CTS的治疗是开发护理质量测量模型的理想背景， 初级保健和专业提供者之间的利用率，鉴于每年约有40，000名退伍军人 新近被诊断患有CTS，并且经常接受来自初级保健的一个或多个提供者的护理， 职业治疗、矫形外科、整形外科、神经外科、物理医学和康复， 或疼痛管理。尽管在某些临床条件下， 在这种情况下，如果这些治疗方法导致本应受益的患者延迟， 从手术室出来这一系列旨在评估和提高CTS术前护理质量和利用率的研究将 推进对如何更广泛地优化以患者为中心的外科护理协调的理解。这 该项目将有三个目标： 目的1：使用VHA国家数据，将通过以下方式评估CTS术前值的机构水平变化： 检查质量/通路（手术延迟不当）和资源利用（术前 同时评估关键结构和过程变量的影响，包括转介给 社区供应商。 目标2：将对患者和临床医生进行半结构化访谈，以进一步识别和改善 了解与术前事件质量和利用率相关的因素。临床医生和患者将 从术前两项性能最高的2家机构和性能最低的2家机构招募 评估观点、偏好、组织因素和护理目标的措施（质量和利用率） 影响术前CTS各阶段决策的关键利益相关者（患者和提供者） 在乎 目标3：目标1和目标2的发现将用于设计和试点多学科CTS临床护理 解决影响术前事件质量/访问的系统性障碍和过程的途径， 利用初级保健和专科诊所提供的CTS相关护理。试点测试将评估 干预的可行性、可接受性和改善设施水平术前事件价值的潜力， 为预期的随机试验做准备。 这些方法，完善了CTS，将在未来的工作中应用，以检查质量和利用率的变化， 其他疾病的术前护理，目标是优化卫生保健服务的使用， 接受手术治疗的退伍军人的结果。在期待更多的退伍军人进入社区- 这一举措也将有利于监测和更好地协调医疗保健的质量和价值， 在不同的医疗保健环境中进行护理。

Episode-based (“bundled”) approaches have been promoted for performance measurement to encourage shared accountability for the quality and efficiency of healthcare delivery among all of the providers involved in a patient's care. Most episode-based pilot programs use relatively narrow episode definitions, with the typical episode trigger starting at the time of a hospitalization or surgery. However, little attention has been paid to measuring quality and value of pre-surgical care. Although inpatient and postoperative care are costly, outpatient care accounts for the greatest utilization of health care resources in terms of visits and expenditures. This pre-surgical period, during which patients often have multiple touches with the healthcare system, is an important time to identify opportunities to improve coordination and quality of care for Veterans. The studies proposed as part of this CDA will facilitate development of innovative strategies to improve coordination, access, and value of care for Veterans with carpal tunnel syndrome (CTS), particularly in the pre- surgical period. Treatment for CTS is an ideal context to develop measurement models of care quality and utilization between primary care and specialty providers, given that approximately 40,000 Veterans per year are newly diagnosed with CTS and often receive care from one or more providers from primary care, occupational therapy, orthopedic surgery, plastic surgery, neurosurgery, physical medicine and rehabilitation, or pain management. Although a variety of nonoperative treatments can be appropriate under certain clinical circumstances, these same treatments can be low value if they lead to delays for patients who would benefit from surgery. This series of studies to evaluate and improve quality and utilization of CTS pre-surgical care will advance an understanding of how to optimize coordination of patient-centered surgical care more broadly. This project will have 3 aims: Aim 1: Using VHA national data, facility-level variation in CTS pre-surgical value will be assessed by examining both quality/access (inappropriate delay of surgery) and resource utilization (number of pre-surgical encounters), while evaluating the impact of key structural and process variables, including referral to community providers. Aim 2: Semi-structured interviews with patients and clinicians will be conducted to further identify and better understand factors associated with pre-surgical episode quality and utilization. Clinicians and patients will be recruited from 2 facilities with the highest and 2 facilities with the lowest performance on both pre-surgical measures (quality and utilization) to evaluate perspectives, preferences, organizational factors, and care goals of key stakeholders (patients and providers) who impact decision-making across phases of pre-surgical CTS care. Aim 3: Findings from Aim 1 and Aim 2 will be used to design and pilot a multi-disciplinary CTS clinical care pathway that addresses systemic barriers and processes impacting pre-surgical episode quality/access and utilization of CTS-related care provided across primary care and specialty clinics. Pilot testing will assess the intervention's feasibility, acceptability, and potential to improve facility-level pre-surgical episode value in preparation for an anticipated randomized trial. These methods, refined for CTS, will be applied in future work to examine variation in quality and utilization of pre-surgical care for other conditions, with the goal of optimizing use of health care services and maximizing outcomes for Veterans who receive surgical care. In anticipation of greater Veteran access to community- based care, this initiative will also be beneficial for monitoring and better coordinating the quality and value of care across diverse healthcare settings.