Reducing Health Systems Costs through a Patient-activation RCT

描述（由申请人提供）：本R21提案是为了响应RFA-RM-10-015预防经济学而提交的。我们提出的随机对照试验（RCT）旨在确定知情的患者是否可以说服医生减少不适当的筛查试验的数量，并增加常规就诊期间订购的适当的预防性筛查试验的数量。多达93%的医生自我报告说他们安排了不必要的检查。总的来说，不必要的测试似乎弊大于利。对患者的伤害可能直接来自检测（如感染、出血或暴露于辐射）或假阳性检测结果。假阳性检测结果往往会导致患者进行进一步的侵入性检测，从而给患者带来心理困扰。不适当的检测还可能造成间接伤害，不必要地增加卫生系统的成本，据估计，每年的成本在500亿至6500亿美元之间。医疗保健费用超过了消费者通货膨胀，成本的增加威胁到《患者保护和平价医疗法案》（PPACA）的长期可行性。广泛的研究表明，知情的病人可以影响医生的行为。我们有一个独特的机会，随机分配了大约1128名主要是年轻健康的硅谷科技公司的女性员工，让他们要么接受3名患者的激活干预，要么只接受健康信息。患者激活干预需要使用一种创新的教育工具，告知患者适合其年龄、性别和疾病的一般风险因素的临床实践。它还提供了如何与医生沟通适当的测试订购行为的指导。后续将通过计费系统和基于网络的自我管理调查自动监测，使我们能够以极低的成本进行随机对照试验。然后，我们将使用这些数据对干预进行成本效益分析。我们还将首次使用随机对照试验（RCT）数据，探讨50岁以下无乳腺癌危险因素的女性因乳房x光假阳性引起的心理困扰。在美国，患者激活是一种政治中立的创新手段，可以提高预防性医疗保健服务的效率。它有可能优化PPACA内的预防性服务提供。但是，如果它通过在患者和提供者的社会网络中传播来改变医学文化，它的效果将是最大的。因此，除此之外，本研究还将用于试点R01，以跟踪行为变化，因为干预在一家大型硅谷科技公司及其供应商网络中的12,500名员工的社交网络中传播。从这些项目中收集的信息——通过全球定位服务以受试者互动跟踪的形式——最终将告知一个基于代理的系统模型，以检查提高美国卫生保健系统效率的策略。

DESCRIPTION (provided by applicant): This R21 proposal is submitted in response to RFA-RM-10-015 the Economics of Prevention. Our proposed randomized controlled trial (RCT) is designed to determine whether well-informed patients can persuade doctors to reduce the number of inappropriate screening tests and increase the number of appropriate preventive screening tests that are ordered during routine medical visits. Up to 93% of doctors self-report ordering unnecessary tests. Unnecessary tests are those that, on balance, appear to produce more harm than good. Harm to the patient can arise directly from the test (e.g., infection, bleeding, or exposure to radiation) or from false positive test results. False positive test results often produce psychological distress for the patient by leading to further invasive testing. Inappropriate testing can also cause indirect harm by needlessly increasing health system costs, and has been estimated to cost between $50 billion and $650 billion annually. Medical care costs outstrip consumer inflation, and cost increases threaten the long-term viability of the Patient Protection and Affordable Care Act (PPACA). A wide range of studies has shown that well-informed patients can influence physician behavior. We have the unique opportunity to randomly assign approximately 1,128 predominately young and healthy female employees at a large Silicon Valley technology firm to either receive a 3patient activation intervention plus a health message or to receive the message alone. The patient activation intervention entails the use of an innovative education tool to inform patients regarding the appropriate clinical practice for their age, gender, and general risk factors for disease. It also provides guidance on how to communicate appropriate test ordering behavior with their physician. Follow-up will be monitored automatically via billing systems and web-based self-administered surveys, allowing us to conduct an RCT at very low cost. We will then use these data to conduct a cost- effectiveness analysis of the intervention. We will also, for the first time, use RCT data to explore psychological distress induced by false positive mammograms among women under 50 years of age who have no risk factors for breast cancer. Patient activation is a politically neutral and innovative means of increasing the efficiency of preventive healthcare delivery in the U.S. It has the potential to optimize preventive service delivery within PPACA. But its effectiveness will be greatest if it changes the culture of medicine by spreading within patient and provider social networks. Therefore, in addition, this study will also serve to pilot an R01 to track behavior change as an intervention spreads through the 12,500 employees within the social network of a large Silicon Valley technology firm and their provider networks. Information gathered from these programs-in the form of subject interaction tracking via Global Positioning Service-will eventually inform an agent-based systems model examining strategies for improving the efficiency of the US health care system.