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

识别、衡量和促进医疗服务去集约化的机会

• 批准号: 9904159
• 负责人: TIMOTHY P. HOFER
• 金额: --
• 依托单位: VETERANS HEALTH ADMINISTRATION
• 依托单位国家: 美国
• 财政年份: 2016
• 资助国家: 美国
• 起止时间: 2016-05-01 至 2020-10-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9904159
• 关键词: Attention; Caring; Clinical; Complement; Consensus; Data Element; Decision Making; Elderly; Electronic Health Record; Ensure; Equilibrium; Frequencies; Functional disorder; Guidelines; Healthcare; Healthcare Systems; Incentives; Intervention; Measurement; Measures; Medical; Medical Records; Methodology; Methods; Monitor; Occupations; Patients; Performance; Policies; Policy Maker; Population; Prevalence; Primary Health Care; Procedures; Process; Provider; Quality of Care; Registries; Reproducibility; Research; Resources; Scanning; Services; Site; System; Testing; Variant; Veterans; Work; comorbidity; diabetic patient; evidence base; health administration; implementation strategy; improved; interest; trend

 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.

 描述（由申请人提供）： 提供适当的卫生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的第一次转型集中在通过绩效管理系统增加必要服务的使用，该系统已成为一套指南，绩效指标，提醒，注册表和激励措施。因此，VHA中必要服务利用不足的情况大幅减少。今天，人们越来越关注识别过度使用-使病人暴露于无益或可能造成伤害的服务，并可能从那些受益者那里夺走稀缺的资源。全国性的“明智选择”运动就是这一趋势的表现之一。虽然这一运动引起了人们的关注，但它并没有产生系统的或可复制的方法来确定过度使用。 在过度使用的一般领域内，一个更集中的目标是促进去强化，当良好的质量实践要求降低目前作为患者持续管理的一部分的医疗服务的强度或频率时。我们越来越认识到，护理过于频繁或过于密集的情况下，边际效益是缺席或有潜在的患者伤害，以及提供者和患者都有特别困难停止常规检测和治疗，一旦他们已经成功地成为患者的常规护理的一部分。其中一个例子是老年糖尿病患者或患有严重合并症的糖尿病患者的强化血糖管理。然而，大多数质量监测和改进举措继续提供基本上没有反对的激励措施，以提高护理强度。 拟议的研究将：1）识别和验证初级保健中去强化治疗的临床适应症（目标1）; 2）评估VHA中去强化治疗措施的流行率和可靠性（目标2）; 3）制定多层次策略，以传播和实施去强化治疗措施（目标3）。目标1将涉及环境扫描，以确定潜在去强化适应症的初步列表;支持候选去强化适应症的现有证据的突袭证据综合; VHA去强化机会的高水平流行率估计;以及专家小组对每种潜在适应症的改善机会、有效性以及测量和实施的可行性进行评级。目标2将包括构建去强化适应症的测量方法，并进行分析，以检查VHA中测量去强化的患病率、方差和可靠性。AIM 3将涉及参与提供者、临床 管理人员和患者在合作决策制定一个操作的测量程序，传播和实施确定的去集约化措施。每个目标的结果将综合成实际的干预战略。由VHA和国家政策、内容和测量专家组成的咨询理事会将在所有阶段与研究团队合作，审查结果，并就适应症测量优先级、可行性、实施和传播提供指导。识别，测量和理解如何促进去强化-以补充促进适当强化的许多措施-对于恢复VHA提高护理质量的努力的平衡至关重要。本研究将开发一种系统的方法，以确定何时需要去强化，评估VHA中去强化发生的频率，并提供可靠测量和部署去强化措施的方法。该项目是独一无二的，涉及所有利益相关者，包括临床和政策专家，一线供应商，临床领导者和患者，制定一个可操作的测量程序和实施方法，可以确保可靠的测量，促进质量改进，并避免组织功能障碍。