Towards Reduction of Harmful Overuse of Healthcare in Older Adults

项目摘要 尽管自2013年美国国家医学院的报告以来， 描述了一条以更低的成本获得最佳护理的道路，但我们并没有达到我们需要达到的目标。我的研究议程 是进行以病人为导向的研究，促进我们对过度使用医疗保健的理解， 老年人在初级研究人员和其他学员的合作下，我将进行研究， 了解卫生保健系统如何通过其 医疗保险受益人通过提供高质量的初级保健。在过去的四年里， 我的团队和我已经认识到，目前还没有一个全面的了解， 在患者、临床医生和系统层面过度使用的驱动因素，以及 干预措施尚未确定。我们开发了约翰霍普金斯过度使用指数， 可以衡量医疗资源过度使用的区域差异的程序。该指数一直 作为一项成果衡量标准是有用的，并使我们能够证明更高的区域性的有益影响。 初级保健医生的密度对减少医疗保险受益人和年轻人的过度使用， 商业保险的人。我试图了解高质量的初级保健的机制， 通过混合方法评估积极偏离，减少老年人过度使用资源 卫生系统，并通过中介分析对初级保健服务的各个组成部分进行建模 方法. 我还旨在通过解决一个基本问题来改善老年人护理方面的决策： 治疗效果（HTE）的不被重视的异质性导致老年人过度使用医疗保健， 成年人了老年人过度使用医疗保健的风险特别高;这既是一个离散的 所有成年人的亚群，和一个人口之间有很大的变化本身。贡献者 变化包括生理差异，可归因于年龄过程中的显著差异， 表现为脆弱或健壮的个体，以及由于 老年人对干预措施的偏好，以及他们从事自我护理的能力。 第二组拟议的项目将涉及开发方法和工具，以帮助临床医生 在这个问题上，彼此之间以及与患者之间进行更清晰的沟通。使用设计思维 方法和合作者从我们的艺术应用于医学系的参与，我会 制定一个框架和视觉工具，以协助就这一主题进行明确的沟通。

Project Summary Although there has been remarkable progress since the National Academy of Medicine’s report in 2013 describing a path towards Best Care at Lower Cost, we are not where we need to be. My research agenda is to conduct patient-oriented research that advances our understanding of overuse of healthcare among older adults. With the collaboration of junior investigators and other mentees, I will conduct research to understand how health care systems reduce the harmful overuse of healthcare resources by their Medicare beneficiaries through their delivery of high quality primary care. In the last four years of my funded work, my team and I have come to recognize that there is not yet a comprehensive understanding of drivers of overuse at the levels of the patient, clinician, and system, and the most optimal points for interventions are not yet defined. We developed the Johns Hopkins Overuse Index which is an index of 20 procedures that can measure regional variation in the overuse of healthcare resource. The index has been useful as an outcome measure and has allowed us to demonstrate the beneficial impact of higher regional density of primary care doctors on reducing overuse both among Medicare beneficiaries and younger, commercially insured people. I seek to understand the mechanisms by which high quality primary care reduces overuse of resources in older adults through a mixed-methods evaluation of positively deviating health systems and through modeling components of primary care delivery with mediation analysis methods. I also aim to improve the decisions made in the care of older adults by addressing a fundamental problem: that unappreciated heterogeneity of treatment effect (HTE) contributes to overuse of healthcare in older adults. Older adults are at particularly high risk of overuse of healthcare; this is both a discrete subpopulation of all adults, and a population with great variation amongst itself. Contributors to this variation include physiological differences attributable to marked variances in the aging process across individuals that manifests as frailty or robustness, as well as differences that arise due to the degree of multimorbidity, older adults’ preferences regarding interventions, and their ability to engage in self-care. The second proposed set of projects will involve the development of methods and tools to help clinicians to communicate more clearly with each other and with patients on this topic. With use of Design Thinking methods and engagement of collaborators from our Department of Art as Applied to Medicine, I will develop a framework and visual tools to assist with clear communication on this topic.