Combining Policy and Implementation Science to Optimize Clinical Practice

项目摘要：改变临床医生的做法虽然困难，但很重要。传统上， 实现可持续实践变革的战略遵循了两条一般路径之一：财政激励 并实践重新设计和实施。财政激励虽然通常在总体上是有效的，但往往会 跨个人和系统的异质影响。实践设计和实施，同时允许 高度定制的本地解决方案是资源密集型解决方案，因此很难跨环境和人群进行扩展。 我们假设这两种战略可以一起部署，增强各自的优势和 减轻他们的弱点。首席调查员在她正在进行的K08奖中，确定了术前 患者优化作为影响临床医生实践改变的新模式的理想案例研究。坚持 术前管理肥胖、吸烟和糖尿病的最佳做法可以减少手术并发症 高达40%。尽管有令人信服的临床病例，但外科医生坚持术前患者优化 仍然出人意料地低。她的工作突出了外科医生坚持不懈的最重要障碍。第一, 外科医生几乎没有经济上的动机来推迟手术，这表明经济上的激励是潜在的 快速使外科医生的实践与患者的术前优化保持一致。第二，与资源相关的障碍 确定了患者优化、组织文化和已建立的实践模式；突出了 需要其他行为改变策略，例如临床医生面临教育和行为改变 干预术前计划(PREP)和现场促进以克服组织和实践 障碍。此建议基于这些K08调查结果来部署和测试一种新的组合：1)策略 创建具有2)实施科学战略的财务激励(政策评估)(通过添加以下内容 向政策非响应者提供资源)，以创建有效和可扩展的计划，以改进实践。这个 该项目将利用密歇根州外科质量合作(MSQC)，这是一个成熟的，全州范围的注册机构 密歇根州70家医院参与的改善联盟。我们将利用一个独特的 有机会对最近推出的绩效工资(P4P)计划进行自然实验(目标1) 与非应答者序贯多分配随机试验(SMART)试验(AIMS 2和 3)测试PREP和现场促进员在改善现场表现不佳或非现场情况方面的有效性 对P4P激励的回应。智能设计允许测试应用更高资源的策略 只有在没有通过较低的资源干预来促进变化时才进行干预，明确认识到 资源密集度和可伸缩性之间的权衡。拟议的研究将立即和 通过开发和验证提高患者依从性的最佳策略产生重大影响 全州医疗系统的优化。更广泛地说，该项目将为新颖的自适应 实施战略，可根据其他重要的做法差距加以调整。

PROJECT SUMMARY ABSTRACT: Changing clinician practice is difficult but important. Traditionally, strategies to attain sustainable practice change have followed one of two general paths: financial incentives and practice redesign and implementation. Financial incentives, while often effective in aggregate, tend to have heterogeneous effects across individuals and systems. Practice design and implementation, while allowing for highly tailored local solutions, is resource intensive and thus difficult to scale across settings and populations. We hypothesize that the two strategies can be deployed together, augmenting their respective strengths and mitigating their weaknesses. The Principal Investigator, in her ongoing K08-award, identified preoperative patient optimization as an ideal case study for new models effecting clinician practice change. Adherence to best practices that manage obesity, smoking, and diabetes preoperatively can reduce surgical complications by up to 40%. Despite the compelling clinical case, surgeon adherence to preoperative patient optimization remains surprisingly low. Her work highlighted the most important barriers to surgeon adherence. First, surgeons have little financial incentive to delay surgery, suggesting the potential for financial incentives to quickly align surgeon practices with patient preoperative optimization. Second, barriers related to resources for patient optimization, organizational culture, and established practice patterns were identified; highlighting the need for additional behavior change strategies such as a clinician facing educational and behavior change intervention PREoperative Program (PREP) and onsite facilitation to overcome organizational and practice barriers. This proposal builds on these K08 findings to deploy and test a novel combination of: 1) a policy creating a financial incentive (policy evaluation) with 2) implementation science strategies (by adding these resources to policy non-responders) to create an effective and scalable program to improve practice. The project will leverage the Michigan Surgical Quality Collaborative (MSQC), a well-established, statewide registry and improvement consortium involving 70 hospitals in Michigan. We will take advantage of a unique opportunity to conduct a natural experiment of a recently launched pay-for-performance (P4P) program (Aim 1) combined with a non-responder Sequential Multiple Assignment Randomized Trial (SMART) trial (Aims 2 and 3) to test the effectiveness of PREP and an onsite facilitator on augmenting site underperformance or non- response to the P4P incentive. The SMART design allows for testing a strategy of applying higher resource intervention only when the change was not facilitated with a lower resource intervention, explicitly recognizing the trade-off between resource intensity and scalability. The proposed study will have immediate and significant impact by developing and validating optimal strategies for improving adherence to patient optimization across a statewide health system. More broadly, the project will inform novel adaptive implementation strategies that could be scaled to other important practice gaps.