(PQE3)A Statewide RCT to Reduce Use of Ineffective or Unproven Breast Cancer Care

描述(由申请者提供)：在舆论、同行和国会预算办公室的挑战下，一些专科学会最近开始制定相对昂贵的五大程序清单，这些程序至少没有为通常为其开具处方的某些类别的患者提供有意义的好处。由美国内科医学委员会开发并得到大多数主要医学专业协会支持的Choose Wisly(R)活动就是最明显的例子。然而，这些名单的发展在多大程度上影响了医生或患者的行为仍不清楚。在此应用程序中，我们将使用威斯康星州医疗质量协作(WCHQ)作为实验室，在该实验室中检查两种组织干预措施的有效性：(I)在公共网站上汇总有关针对乳腺癌的目标无效或未经证实的干预措施的实践级统计数据的“基本”公共报告干预措施；以及(Ii)“增强”干预措施，通过基于智能手机的应用程序(App)增强公共报告，该应用程序可为提供者提供即时信息、决策工具、以及个性化的患者教育材料，支持根据Choose Wisly(R)或国家肿瘤学会指南减少乳腺癌干预措施的使用。具体地说，我们的目标是：(1)利用市场扫描和联邦医疗保险索赔数据，同时根据可能的混杂因素和时间趋势进行调整，检查基本公共报告是否减少了处于干预状态的当代乳腺癌患者队列中与对照州的常规护理相比，针对性乳腺癌做法的使用。(2)使用适用于WCHQ提供者的整群随机设计来检验增强干预相对于基本干预的有效性；以及(3)模拟在全国范围内实施这两种干预措施(相对于彼此和相对于日常护理)所带来的成本节约，并描述这些发现对报销政策和计划倡议的影响。这一结果将为独特的全付费、全年龄公共报告系统的有效性提供严格的证据，该系统有可能出口到其他州，也将为影响提供者行为的新方法(App)提供严格的证据。这一结果对所有对减少无效或未经证实的医疗保健的挑战感兴趣的人都将是重要的，包括政府、政策制定者、付款人、卫生保健提供者和消费者。这一结果将进一步与ACO环境相关，预计这将为提供无效或未经证实的护理提供财政上的阻碍。

DESCRIPTION (provided by applicant): Challenged by public opinion, peers and the Congressional Budget Office, a number of specialty societies have recently begun to develop "Top Five" lists of relatively expensive procedures that do not provide meaningful benefit to at least some categories of patients for whom they are commonly ordered. The Choosing Wisely(R) campaign, developed by the American Board of Internal Medicine and embraced by most of the major medical specialty societies, is the most visible example. The extent to which the development of these lists has influenced the behavior of physicians or patients, however, remains unknown. In this application, we will use the Wisconsin Collaborative for Healthcare Quality (WCHQ), a statewide consortium of hospitals, medical practices, and health systems, as a laboratory in which to examine the effectiveness of two organizational interventions: (i) a "basic" public reporting intervention which summarizes on a public website practice-level statistics regarding use of targeted ineffective or unproven interventions for breast cancer and (ii) an "enhanced" intervention, augmenting public reporting with a smart phone-based application (App) that gives providers just-in-time information, decision-making tools, and personalized patient education materials that support reductions in the use of breast cancer interventions targeted based upon Choosing Wisely(R) or national oncology society guidelines. Specifically, our aims are: (1) To examine whether basic public reporting reduces use of targeted breast cancer practices among a contemporary cohort of patients with incident breast cancer in the intervention state relative to usual care in comparison states, using Marketscan and Medicare claims data while adjusting for possible confounders and temporal trends. (2) To examine the effectiveness of the enhanced intervention relative to the basic intervention using a cluster-randomized design applied to WCHQ providers; and (3) To simulate cost savings forthcoming from nationwide implementation of both interventions (relative to each other and to usual care) and to describe the implications of these findings for reimbursement policy and program initiatives. The results will provide rigorous evidence regarding the effectiveness of a unique all-payer, all-age public reporting system that is potentially exportable to other states, a well as rigorous evidence regarding a novel method (App) for influencing provider behavior. The results will be important for all interested in the challenges of reducing ineffective or unproven care, including government, policy-makers, payers, health care providers, and consumers. The results will be further relevant to the ACO environment, which is expected to provide financial disincentives for providing ineffective or unproven care.