Strategies to Reduce Unnecessary Noninvasive Imaging

背景：患者接受数以百万计的非侵入性诊断成像测试，包括计算机 断层扫描、核磁共振成像和核医学，每年在美国。基于 由专业医学协会制定的适当使用标准(AUC)，其中20%-30%的测试可能是 不适当，即潜在的收益与风险之比没有最大化。关于适当性的有限数据 退伍军人健康管理局(VHA)的成像表明，不适当的使用类似于 在VHA外面。已经采用了各种方法来鼓励更适当地使用非侵入性 成像。其中最流行的是电子决策支持工具(DST)。这些软件产品是 添加到患者护理工作流中，以捕获有意义的AUC数据并减少不必要的测试。最近 VHA证据合成计划(ESP)的报告得出结论认为，对 DST及其使用可能产生的负面后果。此外，VHA的非侵入性成像成本 为了确定不适当的测试的负担，需要进行尚未计算的测试。 具体目标：在这个奖项的过程中，我们将实现以下具体目标：(1)评估潜力 成功采用DST的障碍和促进者，(2)使用 分阶段实施进程，以及(3)通过以下方式评估退伍军人保健系统中DST的财政效力 开发提供非侵入性成像测试的微观成本计算模型。 意义：通过这些调查，我们将收集关于如何调整流程以 改进数以百万计的昂贵测试的排序。如果在减少不必要的测试方面有效，这一结果 该提案最终将改善退伍军人获得护理的机会，并降低辐射风险。 创新：对DST的研究主要集中在有效性上，对 实施过程和可能产生的不利影响，如供应商不满和效率低下。我们的 调查将在研究DST的这些方面开辟新的天地。定性与微观的运用 我们建议的成本计算方法是创新的，因为它们在临床导向研究中的使用不足。 方法：我们将应用实用的稳健实施和可持续发展模型(PRISM)和 理论领域框架(TDF)，以确定该奖项的具体目标。在具体目标1中，我们将使用 定性和定量方法，通过以下方式确定DST实施的可能障碍和促进者 对订购非侵入性检测的供应商进行访谈和调查。在具体目标2中，实施DST 对非侵入性成像的评估将从检测率、不适当的检测比例、 和来自提供商的反馈，分三个不同的步骤进行。首先，被AUC蒙蔽以进行成像测试的提供商将订购 测试照常进行。其次，在订购时，他们将立即收到关于以下内容是否合适的反馈 测试，并提供更改顺序的选项。第三，如果提供者的决定与 AUC，供应商将被要求提供测试订单的理由。这些步骤将帮助我们理解 DST的实施进程，并解决最近的ESP提出的文献中的空白。在……里面 具体目标3，非侵入性成像测试的成本将使用来自行政部门的信息进行计算 数据库，护理服务的时间和动态观察，以及退伍军人的费用日记。 预期结果：我们期待通过这些调查，我们将学习并能够分享 关于实施非侵入性成像的DST的重要教训。这一结果将成为 调查员发起了关于在退伍军人制度内进一步推广DST和适应其他 成像/测试方式，如超声心动图。

Background: Patients undergo millions of noninvasive diagnostic imaging tests, including computed tomography, magnetic resonance imaging, and nuclear medicine, in the United States annually. Based on Appropriate Use Criteria (AUC) developed by professional medical societies, 20-30% of these tests may be inappropriate, i.e., the potential benefit-to-risk ratio is not maximized. Limited data on appropriateness of imaging within the Veterans Health Administration (VHA) suggests that inappropriate use is similar to that outside the VHA. A variety of methods have been employed to encourage more appropriate use of noninvasive imaging. One of the most popular is an electronic decision support tool (DST). These software products are added to patient care workflows to capture meaningful AUC data and reduce unnecessary testing. A recent VHA Evidence Synthesis Program (ESP) report concluded that little is known about the implementation of DSTs and possible negative ramifications of their use. Further, the cost to the VHA of noninvasive imaging testing, which has not been calculated, is needed to determine the burden of inappropriate tests. Specific Aims: In the course of this award, we will achieve the following specific aims: (1) assess potential barriers and facilitators to successful adoption of a DST, (2) determine the effectiveness of a DST using a stepped implementation process, and (3) estimate the fiscal effectiveness of a DST in the VA health system by developing a micro-costing model for delivery of noninvasive imaging tests. Significance: Through these investigations, we will glean valuable insight into how to adjust processes to improve the ordering of millions of costly tests. If effective at reducing unnecessary tests, the results from this proposal will ultimately improve Veterans' access to care and reduce radiation risks. Innovation: Study of DSTs has focused primarily on effectiveness, with little attention paid to the implementation process and possible adverse effects such as provider dissatisfaction and inefficiency. Our investigations will break new ground in studying these aspects of DSTs. The use of qualitative and micro- costing methods as we propose is innovative given their underuse for clinically oriented research. Methods: We will apply the Practical Robust Implementation and Sustainability Model (PRISM) and Theoretical Domains Framework (TDF) to the specific aims for this award. In Specific Aim 1, we will use qualitative and quantitative methods to identify possible barriers and facilitators to DST implementation through interviews and surveys of providers who order noninvasive tests. In Specific Aim 2, implementation of a DST for noninvasive imaging will be assessed from the rate of testing, the proportion of testing that is inappropriate, and feedback from providers in three discrete steps. First, providers blinded to AUC for imaging tests will order tests as usual. Second, at the point of ordering, they will receive immediate feedback on appropriateness of the test and be given the option to change the order. Third, if the provider's decision is not consistent with AUC, the provider will be required to give a justification for the test order. These steps will help us understand the implementation process for DSTs and to address gaps in the literature raised by the recent ESP. In Specific Aim 3, the cost of noninvasive imaging tests will be calculated using information from administrative databases, time-and-motion observation of care delivery, and cost diaries from Veterans. Expected Results: We anticipate that through these investigations, we will learn and be able to share important lessons about implementation of a DST for noninvasive imaging. The results will be the basis for investigator initiated research grants on further spread of DSTs within the VA system and adaptation to other imaging/testing modalities such as echocardiography.