The PIPA (Pediatric Inpatient Patient Pathways for Asthma) Study: Optimizing Quality of Hospital Care for Children with Asthma

 描述(由申请人提供)：这是一份申请K08奖项的申请书，授予加州大学旧金山分校的儿科住院医师Sunitha Kaiser，医学硕士。Kaiser博士正在将自己确立为一名年轻的研究人员，在临床实践中加速使用循证指南，以提高儿童的医院护理质量，儿童是AHRQ优先考虑的人群。 该奖项将为Kaiser博士提供必要的支持，以实现以下目标：(1)成为定性研究方法和实施科学方面的专家；(2)获得进行试验的经验；(3)为设计多地点试验收集初步数据；以及(4)发展独立的临床研究事业。为了实现这些目标，Kaiser博士组建了一个多学科指导委员会，其专业知识涵盖哮喘和临床试验的相关学科(Cabana、McCulloch和Horwitz博士)、医疗服务研究(奥尔巴赫、Cabana、McCulloch和Horwitz博士)、定性研究(Rehm博士)和实施科学(奥尔巴赫、Cabana和Horwitz博士)。哮喘是美国儿科住院的第二大常见原因，每年造成近10亿美元的费用。尽管广泛传播了以循证为基础的哮喘管理指南，但在哮喘住院儿童的护理和风险调整结果方面存在显著差异，这主要是由于将指南纳入护理的挑战。临床路径是为有特定临床问题的患者制定的结构化、多学科和详细的护理计划；它们将证据与实践联系起来，以优化患者结果和交付效率。在对照试验中，路径通过增加家庭哮喘管理教育和减少住院时间来减少护理中的不适当变化，并改善哮喘住院儿童的预后。然而，由于缺乏成功实施方法的循证指导，在真实世界环境中，儿科哮喘途径的表现和吸收存在很大的差异。凯泽博士的长期目标是成为一名独立的调查员，通过加快在临床实践中使用循证指南来领导改善住院儿童护理质量的努力。Kaiser博士的目标是确定、测试和传播路径实施的最佳实践，以提高哮喘住院儿童的护理质量。从“正偏差”方法得出的中心假设是，识别和检查在路径实施方面表现出色的医院可以促进发现和广泛传播改善护理的战略。这种混合方法的步骤包括：1)确定哪些医院的路径实施带来了最大的绩效提升；2)使用定性方法研究这些医院以确定与高绩效相关的最佳实践；以及3)通过严格的设计测试这些最佳实践。其基本原理是，高绩效的医院将拥有可复制的路径实施做法，这将对广泛的全国普及至关重要，最终导致 始终如一地提供循证实践和更高质量的护理。这一假设将通过追求三个具体目标来检验：目标1)确定实施儿科哮喘住院路径导致护理质量改善最大的医院。将对43家为国家行政数据库做出贡献的儿童医院的关键人员进行调查，以确定是否以及何时实施哮喘路径，然后使用该数据库来确定哪些医院通过实施路径在护理质量方面获得了最大进展。目的2)通过对目标1中确定的高绩效医院的关键人员进行深入的定性分析，确定实施住院儿童哮喘路径的最佳做法。目的3)进行试点试验，以确定在三级医院和社区医院利用最佳做法实施住院儿童哮喘路径的可行性。这项试点试验将纳入50名哮喘住院儿童。这项拟议的研究对儿科临床路径研究具有创新性，既改变了传统方法，将重点放在实施策略上，又利用了一种新的混合方法，基于“积极偏离”的概念。这项拟议的研究具有重要意义，因为它预计将垂直推进和扩大关于路径实施最佳实践的知识，这将使第三级和社区环境中的临床路径能够得到更多的吸收和成功实施，从而改善哮喘儿童的循证实践和护理质量。最终，这一新知识可以支持在一系列儿科疾病中实施路径，以提高护理质量并降低不必要的成本。

 DESCRIPTION (provided by applicant): This is an application for a K08 award for Sunitha Kaiser, MD MSc, a pediatric hospitalist at the University of California, San Francisco. Dr. Kaiser is establishing herself as a young investigator in accelerating use of evidence-based guidelines in clinical practice to improve quality of hospital care for children, an AHRQ priority population. This award will provide Dr. Kaiser with the support necessary to accomplish the following goals: (1) to become expert in qualitative research methods and implementation science; (2) to gain experience in conducting a trial; (3) to gather preliminary data for the purpose of designing a multi-site trial; and (4) to develop an independent clinical research career. To achieve these goals, Dr. Kaiser has assembled a multi- disciplinary mentoring committee whose expertise spans the relevant disciplines of asthma and clinical trials (Drs. Cabana, McCulloch and Horwitz), health services research (Drs. Auerbach, Cabana, McCulloch, and Horwitz), qualitative research (Dr. Rehm), and implementation science (Drs. Auerbach, Cabana, and Horwitz). Asthma is the second most common cause of pediatric hospitalizations1 in the United States, resulting in nearly $1 billion in annual costs. Despite broad dissemination of evidence-based guidelines for asthma management, there are significant variations in care and risk-adjusted outcomes for children hospitalized with asthma, largely due to challenges integrating guidelines into care. Clinical pathways are structured, multidisciplinary, and detailed care plans for patients with a specific clinical problem; they link evidence to practice to optimize patient outcomes and delivery efficiency. In controlled trials, pathways reduce inappropriate variation in care and improve outcomes for children hospitalized with asthma by both increasing home asthma management education and decreasing hospital length of stay. However, there is wide variability in performance and uptake of pediatric asthma pathways in real-world settings due to a dearth of evidence- based guidance on successful implementation methods. Dr. Kaiser's long-term goal is to become an independent investigator who leads efforts to improve quality of care for hospitalized children by accelerating use of evidence-based guidelines in clinical practice. Dr. Kaiser's objective is to identify, test, and disseminate best practices for pathway implementation to improve quality of care for children hospitalized with asthma. The central hypothesis, derived from the "positive deviance" approach, is that identification and examination of hospitals that demonstrate exceptional performance with pathway implementation can facilitate the discovery and wide dissemination of strategies to improve care. Steps in this mixed-methods approach include: 1) identify hospitals where pathway implementation led to the largest gains in performance, 2) study these hospitals using qualitative methods to identify best practices associated with high performance, and 3) test these best practices with rigorous design. The rationale is that high-performing hospitals will have replicable pathway implementation practices that will be critical to widespread national uptake, ultimately leading to consistent delivery of evidence-based practices and higher quality of care. This hypothesis will be tested by pursuing three specific aims: Aim 1) Identify hospitals where implementation of inpatient pediatric asthma pathways has led to the largest improvements in quality of care. Key personnel from 43 children's hospitals that contribute to a national administrative database will be surveyed to determine if and when asthma pathways were implemented, then the database will be used to identify which hospitals had the greatest gains in quality of care with pathway implementation. Aim 2) Determine best practices for implementation of inpatient pediatric asthma pathways through in-depth qualitative analysis of key personnel from the high-performing hospitals identified in Aim 1. Aim 3) Conduct a pilot trial to determine the feasibilityof implementing inpatient pediatric asthma pathways utilizing best practices in both a tertiary and community hospital setting. This pilot trial will enroll 50 total children hospitalized with asthma The proposed research is innovative to pediatric clinical pathway research both by shifting the traditional approach to focus on implementation strategies and by utilizing a novel mixed-methodology, based on the concept of "positive deviance." The proposed research is significant because it is expected to vertically advance and expand knowledge on best practices for pathway implementation, which will enable increased uptake and successful implementation of clinical pathways in both tertiary and community settings, thereby improving evidence-based practices and quality of care for children with asthma. Ultimately, this new knowledge could support pathway implementation across a range of pediatric illnesses to improve quality of care and decrease unnecessary costs.