Using Behavioral Science to Improve the Appropriateness of Surgery for Degenerative Lumbar Scoliosis

项目总结/摘要 避免因医疗保健和高医疗保健支出造成的伤害是持续存在的问题， 老年人为了减轻这些问题，改善手术护理是必不可少的，因为手术 占所有严重伤害的一半和所有支出的30%。手术的过度使用和误用 手术率、围手术期并发症和费用的重要驱动因素。 过度使用发生在外科医生手术时，即使对患者的风险超过潜在的好处， 当外科医生没有选择给患者带来最佳风险收益比的手术时，就会发生误用。 适当使用标准（AUC）是严格开发的工具，用于评估 针对个别患者的具体程序。使用AUC将使外科医生能够避免不适当的 虽然目前还没有战略支持在日常实践中实施AUC。行为科学 “轻推”是一种新的和有前途的战略，以改善外科决策，因为轻推可以 在保持自主性的同时影响行为。我们的长期目标是测试手术是否 适当性轻推有助于外科医生常规使用AUC，限制过度使用和误用，并减少 主要手术并发症的外科医生水平差异，使用退行性腰椎侧凸和 脊椎前移为例。许多老年人接受高度复杂，风险和昂贵的手术， 这些与年龄有关的问题。与主要的国家专业协会合作，我们的团队最近开发了 脊柱侧凸的AUC和另一组脊椎前移的AUC相似。 目前的项目将准备我们的团队开发一个随机对照试验的手术 适当性推动支持这些AUC的实施。具体目标是：（1）发展 复杂退行性腰椎疾病的手术适当性，包括（a）设计 通过脊柱疾病、行为科学和信息学专家之间的合作进行推动，（B）进行试点 在两个卫生系统中测试轻推，并根据脊柱外科医生的反馈进行改进;（2） 描述手术选择和手术并发症的外科医生水平差异。实现这些 目标将导致研究中心的外科医生认为可行的轻推， 工作流程，可能有效地提高对AUC的依从性，并可在自己的实践中使用。 此外，记录手术实践和结局中的基线外科医生水平差异将提供 间接证据表明，手术决策可能是次优的，告知轻推的发展， 便于规划未来试验的统计分析。与专业协会密切合作， 大型卫生系统将有助于在全国范围内传播创新的实施战略， 建议发展。如果手术适当性推动是有效的，改善决策和 并发症发生率可能导致更好的患者报告结果和更低的医疗保健成本。

Project Summary/Abstract Avoidable harms due to medical care and high healthcare expenditures are persistent problems among aging adults. To mitigate these problems, improvements in surgical care are essential because surgery accounts for half of all serious harms and 30% of all expenditures. The overuse and misuse of surgery are important drivers of well-documented variations in rates of surgery, perioperative complications, and costs. Overuse occurs when surgeons operate even though the risks to the patient exceed the potential benefits, and misuse occurs when surgeons do not choose the procedure that gives the patient the best risk-benefit ratio. Appropriate use criteria (AUC) are rigorously developed tools for assessing the risk-benefit ratio of a specific procedure for an individual patient. Employing AUC would enable surgeons to avoid inappropriate operations, yet no strategies exist for supporting implementation of AUC in routine practice. Behavioral science “nudges” are a novel and promising strategy for improving surgical decision making because nudges can predictably influence behavior while preserving autonomy. Our longer-term objective is to test whether surgical appropriateness nudges facilitate routine use of AUC by surgeons, limit overuse and misuse, and reduce surgeon-level variation in major operative complications, using degenerative lumbar scoliosis and spondylolisthesis as examples. Many older adults undergo highly complex, risky, and costly operations for these age-related conditions. Working with major national specialty societies, our team recently developed AUC for scoliosis and another group developed similar AUC for spondylolisthesis. The current project will prepare our team to develop a randomized controlled trial of surgical appropriateness nudges supporting the implementation of these AUC. Specific Aims are: (1) to develop surgical appropriateness nudges for complex degenerative lumbar spine conditions, including (a) to design nudges via collaboration among experts in spine disorders, behavioral science, and informatics and (b) to pilot test the nudges in two health systems and refine them based on spine surgeons' feedback; and (2) to characterize surgeon-level variation in the choice of procedure and operative complications. Achieving these aims will lead to nudges that surgeons at study sites will perceive as feasible for incorporation into the surgical workflow, potentially effective at improving adherence to AUC, and acceptable for use in their own practice. Additionally, documenting baseline surgeon-level variation in surgical practices and outcomes will provide indirect evidence that surgical decision making is probably suboptimal, inform the development of nudges, and facilitate planning for statistical analyses in the future trial. Working closely with specialty societies and two large health systems will facilitate national dissemination of the innovative implementation strategies that we propose to develop. If surgical appropriateness nudges are effective, improvements in decision making and complication rates are likely to lead to better patient-reported outcomes and lower healthcare costs.