UNderstanding the Delivery of Low-Value CAre To CHildren and the Barriers to De-Implementation (UN-LATCH)

项目总结 低价值护理，或提供没有净效益的护理，与患者伤害和数十亿美元有关 不必要的医疗费用18，19其中一个例子是为病毒性上呼吸道开抗生素 感染(URI)。据估计，超过50%的呼吸道感染抗生素处方是 不必要的，每年花费超过7亿美元。20抗生素可以增加抗菌素耐药性，并导致 10%的患者发生不良事件。21选择明智的倡议已有80多个专科加入 包括美国儿科学会在内的社会团体提出反对低价值护理的建议。 尽管有这些建议，每年仍有十分之一的儿童受到低价值护理的影响。 未来涉及基于索赔的审计和反馈的去实施研究，我们选择了三种类型 基于高普及率的儿科低价值护理22以及利用索赔区分低价值护理的能力 数据：1)治疗病毒性尿毒症的抗生素，2)健康儿童的维生素D筛查，3)婴儿的抗酸药物 回流。目前还不清楚供应商在多大程度上熟悉这些针对低- 重视关怀。即使提供者知道反对低价值护理的建议，也可能存在其他障碍 去实现这种有利于历史实践的认知偏见，对诊断的不确定性感到不适 23在目标1中，我们将首先评估患者(年龄、种族、性别、 保险类型)、提供者(医疗专科)和系统层面的因素(临床环境、医疗保健系统、 乡村)与三种不同类型的低价值护理相关联。在目标2中，我们将询问提供者有关1) 了解，2)同意，3)关于这三个明智选择的建议的行动。我们 将使用实施研究综合框架(CFIR)框架24-26访问子集 关于取消实施的障碍的供应商。我们将利用这些信息来设计一个有针对性的、有效的 可以在整个弗吉尼亚州联邦使用的取消执行战略。 这项建议建立在沃尔夫博士的KL2研究基础上，该研究与提供循证、高价值的护理和她的 普通儿科的临床培训。临床和转化研究中心(CTSA)将支持使用 在所有付款人索赔数据库(APCD)和由Krist博士和Sabo博士提供的指导下，他们拥有患者- 面向卫生服务研究与实施的科学。在研究期间，沃尔夫博士将发表讲话 关于是什么推动了儿童低价值护理的提供，以及是什么阻止了 防止供应商放弃实施低价值做法。通过让提供者参与她的研究，她将设计一种 与他们的价值观、偏好和目标一致的干预。最终，这项提案将允许Dr。 沃尔夫将建立一个更大的研究计划，研究以系统为导向、以患者为中心的解决方案，以减少低成本 重视对儿童的关怀。

PROJECT SUMMARY Low-value care, or the provision of care without net benefit, is associated with patient harm and billions of dollars in unnecessary medical costs.18,19 One example is the prescription of antibiotics for viral upper respiratory infections (URIs). It is estimated that over 50% of antibiotic prescriptions for respiratory infections are unnecessary and cost over $700 million per year.20 Antibiotics can increase antimicrobial resistance, and cause adverse events in 10% of patients.21 The Choosing Wisely initiative has been joined by over 80 specialty societies, including the American Academy of Pediatrics, to develop recommendations against low-value care. Despite these recommendations, low-value care continues to affect one in ten children every year.22 To plan for future de-implementation research involving claims-based audit and feedback, we selected three types of pediatric low-value care based on high prevalence22 and the ability to distinguish low-value care using claims data: 1) antibiotics for viral URIs, 2) vitamin D screening in healthy children and 3) antacid medications for infant reflux. It is not well understood to what extent providers are familiar with these recommendations against low- value care. Even if a provider is aware of recommendations against low-value care, there can be other barriers to de-implementation such cognitive biases that favor historical practices, discomfort with diagnostic uncertainty or unease in discussing low-value care with families.23 In Aim 1, we will first evaluate the patient (age, race, sex, insurance type), provider (medical specialty) and system-level factors (clinical setting, healthcare system, rurality) associated with the three different types of low-value care. In Aim 2, we will query providers about 1) knowledge of, 2) agreement with, and 3) actions regarding the three Choosing Wisely recommendations. We will use the Consolidated Framework for Implementation Research (CFIR) framework24-26 to interview a subset of providers about barriers to de-implementation. We will use this information to design a targeted and effective de-implementation strategy that can be used across the Commonwealth of Virginia. This proposal builds on Dr. Wolf's KL2 study related to the delivery of evidence-based, high-value care and her clinical training in general pediatrics. The Center for Clinical and Translational Research (CTSA) will support use of the All-Payers Claims Database (APCD) and mentorship by Drs. Krist and Sabo who have expertise in patient- oriented health services research and implementation science. During the study period, Dr. Wolf will address critical gaps of knowledge about what drives the delivery of low-value care in children and what prevents providers from de-implementing low-value practices. By engaging providers in her research, she will design an intervention that is consistent with their values, preferences, and goals. Ultimately, this proposal will allow Dr. Wolf to build a larger research program to investigate system-oriented, patient-centered solutions to reduce low- value care for children.