(PQE3)A Statewide RCT to Reduce Use of Ineffective or Unproven Breast Cancer Care

描述（由申请人提供）：在公众舆论、同行和国会预算办公室的挑战下，一些专业协会最近开始制定“五大”相对昂贵的手术清单，这些手术至少对某些类别的患者没有提供有意义的益处。由美国内科医学委员会（American Board of Internal Medicine）发起并受到大多数主要医学专业协会欢迎的“明智选择”（Choosing Wisely， R）运动就是最明显的例子。然而，这些清单的发展在多大程度上影响了医生或患者的行为仍不得而知。在本应用程序中，我们将使用威斯康星州医疗保健质量协作组织（WCHQ），一个全州范围内的医院、医疗实践和卫生系统联盟，作为实验室来检查两个组织干预措施的有效性：(i)“基本”公共报告干预，在公共网站上总结有关使用有针对性的无效或未经证实的乳腺癌干预措施的实践水平统计数据；（ii）“增强”干预，通过基于智能手机的应用程序（App）增加公共报告，为提供者提供及时的信息，决策工具，以及个性化的患者教育材料，支持减少使用基于明智选择(R)或国家肿瘤学会指南的乳腺癌干预措施。具体而言，我们的目标是：(1)在调整可能的混杂因素和时间趋势的同时，使用Marketscan和Medicare索赔数据，研究在干预状态下，与比较状态下的常规护理相比，在当代乳腺癌患者队列中，基本的公共报告是否减少了靶向乳腺癌治疗的使用。(2)采用聚类随机设计对WCHQ提供者进行强化干预相对于基本干预的有效性检验；(3)模拟在全国范围内实施这两种干预措施（相对于彼此和常规护理）所带来的成本节约，并描述这些发现对报销政策和计划举措的影响。研究结果将为一个独特的所有付款人、所有年龄的公共报告系统的有效性提供严格的证据，该系统可能会出口到其他州，同时也将为影响提供者行为的新方法（App）提供严格的证据。研究结果对所有对减少无效或未经证实的医疗服务挑战感兴趣的人都很重要，包括政府、决策者、付款人、卫生保健提供者和消费者。结果将进一步与ACO环境相关，预计将为提供无效或未经证实的护理提供财政激励。

DESCRIPTION (provided by applicant): Challenged by public opinion, peers and the Congressional Budget Office, a number of specialty societies have recently begun to develop "Top Five" lists of relatively expensive procedures that do not provide meaningful benefit to at least some categories of patients for whom they are commonly ordered. The Choosing Wisely(R) campaign, developed by the American Board of Internal Medicine and embraced by most of the major medical specialty societies, is the most visible example. The extent to which the development of these lists has influenced the behavior of physicians or patients, however, remains unknown. In this application, we will use the Wisconsin Collaborative for Healthcare Quality (WCHQ), a statewide consortium of hospitals, medical practices, and health systems, as a laboratory in which to examine the effectiveness of two organizational interventions: (i) a "basic" public reporting intervention which summarizes on a public website practice-level statistics regarding use of targeted ineffective or unproven interventions for breast cancer and (ii) an "enhanced" intervention, augmenting public reporting with a smart phone-based application (App) that gives providers just-in-time information, decision-making tools, and personalized patient education materials that support reductions in the use of breast cancer interventions targeted based upon Choosing Wisely(R) or national oncology society guidelines. Specifically, our aims are: (1) To examine whether basic public reporting reduces use of targeted breast cancer practices among a contemporary cohort of patients with incident breast cancer in the intervention state relative to usual care in comparison states, using Marketscan and Medicare claims data while adjusting for possible confounders and temporal trends. (2) To examine the effectiveness of the enhanced intervention relative to the basic intervention using a cluster-randomized design applied to WCHQ providers; and (3) To simulate cost savings forthcoming from nationwide implementation of both interventions (relative to each other and to usual care) and to describe the implications of these findings for reimbursement policy and program initiatives. The results will provide rigorous evidence regarding the effectiveness of a unique all-payer, all-age public reporting system that is potentially exportable to other states, a well as rigorous evidence regarding a novel method (App) for influencing provider behavior. The results will be important for all interested in the challenges of reducing ineffective or unproven care, including government, policy-makers, payers, health care providers, and consumers. The results will be further relevant to the ACO environment, which is expected to provide financial disincentives for providing ineffective or unproven care.