Medical reversals: De-implementing ineffective and unsafe treatments

摘要 了解是否以及如何将强有力的临床证据整合到实践中是至关重要的 观点：a)改善患者的安全和健康结果；b)设计方案和政策以 加快使用高价值、有效的治疗方法，放弃效果较差和有害的治疗方法；c) 通过将有限的卫生保健预算分配到最有效的用途来控制卫生保健成本。在大多数 环境、医生和医疗保健提供组织(HCDO)是决定 病人是否接受了特定的医疗治疗。然而，内科医生与HCDO的临床整合 实践中的证据没有得到很好的研究或理解。一般而言，“证据与证据的结合”这一术语 实践“，可能意味着采用新的治疗方法和取消已有的治疗方法 基于与有效性或安全性有关的新证据。在这项建议中，我们将重点放在后者上。 我们的主要关注点是了解医生网络、HCDO和医生市场环境 在实践中影响无效和不安全治疗的去实施。因此，我们有 以下目标： 目标1：描述医生之间无效和不安全治疗的取消实施的差异 和HCDO。 目标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(即执业规模、专科组合、所有权、集成水平)、医生的 患者共享网络(即中间性中心)和医生的市场环境(竞争， 医疗事故环境)影响医生不实施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 关于医生无效实施的可能性的网络(由HCDO从属关系和患者共享定义) 和不安全的治疗。 我们将专注于不同的案例研究，这些研究涉及到心血管疾病的治疗。 结果和安全性。我们的研究样本将包括联邦医疗保险按服务收费(FFS)人群(从 CMS)以及商业保险和医疗保险优势(MA)人群(Optom Labs)。

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).