Medical reversals: De-implementing ineffective and unsafe treatments

摘要 了解是否以及如何将强大的临床证据整合到实践中至关重要， 从以下角度：a）改善患者安全和健康结果; B）设计方案和政策， 加速使用高价值、有效的治疗方法，放弃不太有效和有害的治疗方法; 通过将有限的卫生保健预算分配给最有效的用途来控制卫生保健费用。在大多数 在这种情况下，医生和卫生保健提供组织（HCDO）是确定 患者是否接受了特定的治疗。然而，医生和HCDO的临床整合 没有很好地研究或理解将证据付诸实践。一般而言，“将证据纳入 实践”，可能意味着采用新的治疗方法和取消现有治疗方法 基于与有效性或安全性相关的新证据。在本提案中，我们将重点关注后者。 我们的主要重点是了解医生网络，HCDO和医生市场环境 影响在实践中取消无效和不安全的治疗。因此，我们有 以下目标： 目的1：描述医生之间无效和不安全治疗的取消实施的差异 和HCDOs。 目的2：调查医生的特征（即年龄、性别、医学院毕业年限或 住院医师、患者组合）、HCDO（即实践规模、专业组合、所有权、整合水平）、医生的 患者共享网络（即中介中心性）和医生的市场环境（竞争， 医疗事故环境）影响医生取消无效和不安全的治疗。 目的3：评估无效或不安全治疗的取消对医生的影响。 网络（由HCDO附属机构和患者共享定义）对医生的可能性，以取消实施无效 不安全的治疗。 我们将重点介绍与心血管疾病相关的治疗方法的不同案例研究。 结果和安全性。我们的研究样本将包括医疗保险收费服务（FFS）人群（从 CMS）以及商业保险和医疗保险优势（MA）人群（OptumLabs）。

Abstract Understanding whether and how robust clinical evidence is integrated into practice is critical from the perspectives of: a) improving patient safety and health outcomes; b) designing programs and policies to accelerate the use of high value, effective treatments and abandon less effective and harmful treatments; c) containing health care costs by allocating limited health care budgets to their most effective use. In most circumstances, physicians and health care delivery organizations (HCDOs) are the key agents in determining whether a patient receives a given medical treatment. However, physician and HCDO integration of clinical evidence into practice is not well studied or understood. In general, the term “integration of evidence into practice”, could mean both the adoption of new treatments and de-implementation of established treatments based on new evidence related to effectiveness or safety. In this proposal, we will focus on the latter. Our primary focus is to understand how physician networks, HCDOs and physician market environment influence the de-implementation of ineffective and unsafe treatments in practice. As such, we have the following aims: Aim 1: To describe variation in the de-implementation of ineffective and unsafe treatments across physicians and HCDOs. Aim 2: To investigate how characteristics of the physician (i.e. age, gender, years since medical school or residency, patient-mix), HCDO (i.e. practice size, specialty mix, ownership, level of integration), physician's patient sharing network (i.e. betweenness centrality), and physician's market environment (competition, malpractice environment) influence de-implementation of ineffective and unsafe treatments by physicians. Aim 3: To assess the influence of de-implementation of ineffective or unsafe treatments in the physicians' network (defined by HCDO affiliation and patient-sharing) on physicians' likelihood to de-implement ineffective and unsafe treatments. We will focus on different case studies concerning treatments with implications for cardiovascular outcomes and safety. Our study sample will include the Medicare Fee-For Service (FFS) population (from CMS) as well as the commercially insured and Medicare Advantage (MA) populations (OptumLabs).