Watchful Waiting as a Strategy for Reducing Low-value Spinal Imaging

观察等待作为减少低价值脊柱成像的策略

• 批准号: 10237154
• 负责人: Joshua J Fenton
• 金额: $ 37.08万
• 依托单位: UNIVERSITY OF CALIFORNIA AT DAVIS
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-09-01 至 2023-08-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10237154
• 关键词: Watchful; Waiting; Strategy; Reducing; Low

PROJECT SUMMARY Overutilization is increasingly viewed within the framework of patient safety. In primary care, patients with acute low back pain frequently request diagnostic imaging, and primary care physicians (PCPs) feel pressure to acquiesce to such requests to sustain patient trust and satisfaction. Spinal imaging in patients with acute low back pain poses risks from diagnostic evaluation of false-positive findings, patient labeling and anxiety, and unnecessary treatment (including spinal surgery) with potential downstream complications. Watchful waiting advice has been found an effective strategy to reduce low-value treatment (e.g., pediatric ear infections), and some evidence suggests a watchful waiting approach would be acceptable to many patients requesting tests. Meanwhile, psychological theory (regulatory fit vs. non-fit) suggests that physician messages could be tailored to magnify patient acceptance of a watchful waiting strategy. In response to the Agency Healthcare Quality and Research's interest in advancing simulation research to improve patient safety, we propose to refine and evaluate a novel simulated intervention using standardized patients (SPs) -- or actors playing the roles of patients – to teach PCPs to endorse a watchful waiting approach when patients request low-value spinal imaging for low back pain. Specific aims are: Aim 1: To use key informant interviews of front-line PCPs and focus groups with primary care patients to refine a theory-informed standardized patient-based intervention designed to teach practicing PCPs how to advise watchful waiting when patients request low-value spinal imaging for low back pain. Aim 2: To test the effectiveness of standardized patient instructor (SPI)-delivered PCP training in the use of watchful waiting in a randomized clinical trial. We hypothesize that the intervention will: a) reduce rates of low-value spinal imaging among actual patients with acute back pain seen by PCPs post-intervention (adjusting for pre-RCT rates); b) increase PCP advice to pursue watchful waiting during a followup visit with a previously unseen SP; c) increase PCP self- reported use and efficacy of advising watchful waiting with actual low back pain patients; and d) have no adverse impact on actual patient trust and satisfaction with physicians. Aim 3: To assess whether the intervention effects generalize to other high-cost, low-value imaging tests. We hypothesize that the SP intervention will: a) decrease rates of advanced neck imaging among actual patients with neck pain seen by study PCPs during the follow-up period (adjusting for baseline rates), and b) increase PCP self-reported use and efficacy of advising watchful waiting rather than imaging for patients with neck pain and other musculoskeletal pain.

项目摘要 在患者安全的框架内，人们越来越多地观察过过度利用。在初级保健中 急性下背部疼痛经常要求诊断成像，而初级保健医生（PCP）感到 要收取此类请求以维持患者的信任和满意度的压力。患者的脊柱成像 急性下背部疼痛从假阳性发现，患者标签和 焦虑和不必要的治疗（包括脊柱手术），并有潜在的下游并发症。 已经发现了注意的等待建议是减少低价值治疗的有效策略（例如， 小儿耳朵感染），一些证据表明，警惕的等待方法是可以接受的 许多患者要求进行检查。同时，心理理论（法规合身与非拟合）表明 可以量身定制的医师信息以扩大患者接受注意等待策略的接受。 回应机构医疗保健质量和研究对推进模拟研究的兴趣 为了提高患者的安全，我们建议使用标准化来完善和评估新的模拟干预措施 患者（SP）或演员扮演患者的角色 - 教PCPS认可警惕的等待方法 当患者要求低价值的脊柱成像以减轻腰痛。具体目的是： 目标1：使用前线PCP和焦点小组的主要线人访谈与初级保健 患者完善理论知识的标准化基于患者的干预措施，旨在教 练习PCP，当患者要求低价值脊柱成像时，如何建议注意等待 腰背疼痛。 目标2：测试标准化患者讲师（SPI）授予的PCP培训的有效性 在随机临床试验中使用注意力等待。 我们假设干预将：a）降低实际之间低价值脊柱成像的速率 干预后PCP看到急性背痛的患者（调整RCT率）； b）增加PCP 在随访期间与以前看不见的SP进行后续访问期间，购买注意力等待的建议； c）增加PCP自我 据报道使用和易于观察的咨询等待，与实际的下背痛患者一起等待； d）没有 对实际患者信任和对医生的满意的不利影响。 目标3：评估干预效果是否概括为其他高成本，低价值 成像测试。 我们假设SP干预将：a）降低高级颈部成像速率 在随访期间，研究PCP看到的实际颈部疼痛患者（调整基线率）， b）增加PCP自我报告的使用和易于注意的咨询等待，而不是成像 颈部疼痛和其他肌肉骨骼疼痛的患者。