Identifying, Measuring, and Facilitating Opportunities for De-intensification of Medical Services

 描述(由申请人提供)： 提供适当的医疗保健意味着确保患者得到他们需要的护理，同时避免不必要或有害的护理。在20世纪90年代，VHA的第一次转型侧重于通过业绩管理系统增加必要服务的使用，该系统已成为一整套指导方针、业绩衡量、提醒、登记和激励措施。因此，VHA的必要服务利用不足的情况大大减少。今天，人们越来越感兴趣的是识别过度使用的护理，这种护理将患者暴露在无益或可能造成伤害的服务中，并可能从受益的人手中夺走稀缺的资源。全国性的明智选择运动就是这一趋势的表现之一。虽然这项运动引起了人们的注意，但它并没有产生系统的或可重复的方法来确定过度使用。在过度使用的一般领域内，当高质量的实践要求降低目前作为患者持续管理一部分的医疗服务的强度或频率时，更有针对性的目标是促进去强化。我们越来越认识到，在没有边际效益或有可能对患者造成伤害的情况下，护理过于频繁或过于密集，而且一旦常规检测和治疗成功地成为患者常规护理的一部分，提供者和患者都特别难以停止。一个例子是对老年或有主要合并症的糖尿病患者进行强化血糖治疗。然而，大多数质量监测和改进倡议继续提供基本上无人反对的激励措施，以提高护理强度。拟议的研究将：1)确定和验证初级保健去强化的临床适应症(目标1)；2)评估VHA去强化措施的流行率和可靠性(目标2)；以及3)制定多层次战略来传播和实施去强化措施(目标3)。目标1将包括环境扫描，以确定潜在去强化适应症的初步清单；对支持候选去强化适应症的现有证据的突袭证据合成；对VHA去强化机会的高水平流行率估计；以及专家小组，就改善机会、有效性以及衡量和实施的可行性对每一种潜在迹象进行评级。目标2将包括构建去强化指征的措施，并进行分析，以检查VHA中测量去强化的流行率、变异性和可靠性。目标3将涉及与提供商、临床 管理人员和患者参与协作决策，以制定业务衡量程序，以传播和实施已确定的去强化措施。来自每个目标的结果将被综合成实际的干预策略。由VHA和国家政策、内容和衡量专家组成的咨询委员会将在所有阶段与研究团队合作，审查结果，并就指标衡量的优先顺序、可行性、实施和传播提供指导。确定、衡量和了解如何促进非强化治疗--以补充促进适当强化治疗的许多措施--对于恢复VHA改善护理质量的努力的平衡至关重要。这项研究将开发一种系统的方法来确定何时需要去强化，评估VHA发生去强化的频率，并提供可靠地测量和部署去强化措施的方法。该项目的独特之处在于，所有利益相关者，包括临床和政策专家、一线提供商、临床领导者和患者，都参与制定了可确保可靠测量、促进质量改进和避免组织功能失调的操作测量程序和实施方法。

 DESCRIPTION (provided by applicant): Providing appropriate health care means ensuring that patients get the care they need while avoiding care that is unnecessary or harmful. In the 1990s, VHA's first transformation focused on increasing the use of necessary services through a performance management system that has become a panoply of guidelines, performance measures, reminders, registries, and incentives. As a result, the underuse of necessary services in VHA decreased dramatically. Today, there is growing interest in identifying overuse - care that exposes patients to services that are not beneficial or may cause harm and which may take scarce resources away from those who would benefit from them. The national Choosing Wisely campaign is one manifestation of this trend. While this campaign has garnered attention, it has not produced systematic or reproducible approaches to identify overuse. Within the general realm of overuse, a more focused target is promoting de-intensification when good quality practice calls for decreasing the intensity or frequency of medical services that are currently part of a patient's ongoing management. Increasingly, we recognize that care is too frequent or too intensive in cases where the marginal benefit is absent or there is potential for patient harm, and that both providers and patients have particular difficulty stopping routine testing and treatments once they have successfully become part of a patient's regular care. One example is intensive glycemic management among diabetic patients who are elderly or have major comorbidities. Yet, most quality monitoring and improvement initiatives continue to provide largely unopposed incentives to escalate care intensity. The proposed study will: 1) identify and validate clinical indications for de-intensification in primary care (Aim 1); 2) assess the prevalence and reliabilit of measures of de-intensification in VHA (Aim 2); and 3) develop multi-level strategies to disseminate and implement de-intensification measures (Aim 3). Aim 1 will involve an environmental scan to identify a preliminary list of potential de-intensification indications; a raid evidence synthesis of existing evidence supporting candidate de-intensification indications; a high level prevalence estimate of opportunities for de-intensification in VHA; and, expert panels to rate each of the potential indications on improvement opportunity, validity, and feasibility of measurement and implementation. Aim 2 will include constructing measures of de-intensification indications and conducting an analysis to examine prevalence, variance, and reliability of measuring de-intensification in VHA. AIM 3 will involve engaging providers, clinical managers, and patients in collaborative decision-making to develop an operational measurement procedure for disseminating and implementing the identified de-intensification measures. Findings from each of the Aims will be synthesized into practical intervention strategies. An advisory council, comprised of VHA and national policy, content and measurement experts, will work with the research team in all stages to review results and provide guidance on indication measurement prioritization, feasibility, implementation, and dissemination. Identifying, measuring, and understanding how to promote de-intensification - to complement the many measures promoting appropriate intensification - is critical to restoring balance to VHA's efforts to improve care quality. This study will develop a systematic method to identify when de-intensification is called for, assess how frequently de-intensification occurs in VHA, and provide approaches to reliably measure and deploy measures of de-intensification. The project is unique by involving all stakeholders, including clinical and policy experts, front-line providers, clinical leaders, and patients in developing an operational measurement procedure and implementation approach that can ensure reliable measurement, promote quality improvement, and avoid organizational dysfunction.