Organizational Determinants of ICU Telemedicine Effectiveness

描述(由申请人提供)：在ICU中由经过适当培训的强化临床医生进行治疗可提高危重病人的存活率。然而，许多患者无法获得这种程度的危重护理，特别是在小医院和农村地理区域，导致过高的死亡率，并造成显著的社会经济差距。为了解决这一问题，许多医院采用了ICU远程医疗，这是一种医疗保健服务创新，使用视听技术来提供远程危重护理服务。通过扩大获得高质量危重护理的机会，ICU远程医疗在改善危重患者存活率方面具有巨大潜力 生病了。然而，远程医疗的成功受到我们对如何以及在哪里最好地应用这项技术的严重缺陷的阻碍。远程医疗是一种复杂的干预措施，现有的方案在干预的组成部分和使用干预的临床环境方面都有很大不同。反过来，对远程医疗的研究显示出好坏参半的结果，一些研究显示出很大的死亡率收益，而另一些研究则显示没有好处，甚至提出了危害。因此，对于如何以及在哪里使用这项潜在的变革性技术，决策者几乎没有指导，如果有的话。在这个项目中，我们将通过确定与ICU远程医疗有效性相关的关键临床和组织因素来解决这些知识问题。我们的中心假设是，客观的、可衡量的、临床和组织因素将区分有效的计划和无效的计划。首先，我们将使用国家数据 关于医疗保险受益人和一种创新的风险-量化医院水平变化的调整程序-ICU远程医疗对患者死亡率的影响，对采用ICU远程医疗的每家医院进行从最有效到最不有效的排序。其次，我们将对远程医疗效果最好的五家医院和远程医疗效果最小的五家医院进行实地考察；并对已停止使用ICU远程医疗的医院进行两次实地考察；进行深入的定性分析，以确定与ICU远程医疗效果相关的临床和组织因素。第三，我们将对所有采用ICU远程医疗的美国医院进行调查，将调查结果与患者层面的结果数据联系起来，并定量定义ICU远程医疗临床和组织的“最佳实践”。通过将ICU远程医疗评估的范式从是否有效转变为如何以及在哪里效果最好，该项目将是对成功实施ICU远程医疗的因素的第一次严格审查。最终，这些结果将为临床医生和医院管理人员提供关于如何最有效和高效地使用ICU远程医疗的即时、可操作的数据，直接导致改善获得危重护理的机会 并提高危重病人的存活率。

DESCRIPTION (provided by applicant): Treatment in an ICU staffed by appropriately trained intensivist clinicians improves survival in critically ill patients. Yet many patients lack access o this level of critical care, particularly in small hospital and rural geographic areas, leading to excess mortality and creating significant socioeconomic disparities. To address this problem many hospitals have adopted ICU telemedicine, a health care delivery innovation which uses audio---visual technology to provide critical care services from a distance. By expanding access to high-quality critical care, ICU telemedicine has great potential to improve survival in critical illness. However, the success of telemedicine is hindered by critical deficiencies in our understanding of how and where this technology is best applied. Telemedicine is a complex intervention, and existing programs vary significantly in both the components of intervention and the clinical setting in which it is used. In turn, studies of telemedicine demonstrate mixed result, with some showing a large mortality benefit and others showing no benefit or even suggesting harm. As a result, decision makers have little guidance regarding how and where to use this potentially transformative technology, if at all. In this project we will address this knowledge ga by identifying the key clinical and organizational factors associated with ICU telemedicine effectiveness. Our central hypothesis is that objective, measurable, clinical and organizational factors will distinguish effective programs from ineffective ones. First, we will use national data on Medicare beneficiaries and an innovative risk--- adjustment procedure to quantify hospital---level variation in the impact of ICU telemedicine on patient mortality, ranking each hospital that has adopted ICU telemedicine from most effective to least effective. Second, we will conduct site visits at five hospitals with the greatest telemedicine effect and five hospitals with least telemedicine effect; along with two site visits at hospitals that have stopped using ICU telemedicine; performing in-depth qualitative analyses to identify the clinical and organizational factors associated with ICU telemedicine effectiveness. Third, we will develop and field a survey of all US hospitals that have adopted ICU telemedicine, linking the survey back to patient---level outcomes data and quantitatively defining ICU telemedicine clinical and organizational "best practices". By shifting the paradigm of ICU telemedicine evaluation away from whether it works to how and where it works best, this project will be the first rigorous examination of the factors that define successful ICU telemedicine implementation. Ultimately, these results will provide clinicians, hospital administrators with immediate, actionable data about how to use ICU telemedicine most effectively and efficiently, directly leading to improved access to critical care and improved survival for critically ill patients.