Towards Reduction of Harmful Overuse of Healthcare in Older Adults

项目摘要 尽管自2013年美国国家医学科学院的报告以来已经取得了显著的进展 在描述一条以较低成本实现最佳护理的道路时，我们并没有达到我们需要达到的地步。我的研究议程 是进行以患者为中心的研究，促进我们对过度使用医疗保健的理解 上了年纪的人。在初级调查人员和其他学员的合作下，我将进行研究，以 了解医疗系统如何通过以下方式减少医疗资源的有害过度使用 医疗保险受益者通过提供高质量的初级保健服务。在我生命中的最后四年 资助工作，我和我的团队已经逐渐认识到，目前还没有一个全面的认识 患者、临床医生和系统层面的过度使用驱动因素，以及 干预措施尚未定义。我们开发了约翰·霍普金斯过度使用指数，它是一个20 可以衡量医疗资源过度使用的地区差异的程序。该指数一直是 作为一种结果衡量标准是有用的，并使我们能够展示更高的地区性 初级保健医生在减少医疗保险受益人和年轻人过度使用方面的密度， 有商业保险的人。我试图了解高质量的初级保健服务的机制 通过对正偏差的混合方法评估减少老年人对资源的过度使用 卫生系统和通过对初级保健提供的组成部分进行建模和中介分析 方法：研究方法。 我还致力于通过解决一个根本问题来改善老年人护理方面的决策： 未被认识到的治疗效果的异质性(Hte)导致老年人过度使用医疗保健。 成年人。老年人过度使用医疗保健的风险特别高；这既是一个离散的 所有成虫的亚群，并且种群之间有很大的差异。这其中的贡献者 差异包括可归因于衰老过程中的显著差异的生理差异 表现为脆弱或健壮的个体，以及由于以下情况而产生的差异 多发病、老年人对干预措施的偏好，以及他们从事自我护理的能力。 第二套拟议的项目将涉及开发方法和工具，以帮助临床医生 就这一话题与彼此以及与患者进行更清晰的沟通。运用设计思维 我们艺术系应用于医学的方法和合作者的参与，我将 开发一个框架和可视化工具，以协助就此主题进行清晰的沟通。

Project Summary Although there has been remarkable progress since the National Academy of Medicine’s report in 2013 describing a path towards Best Care at Lower Cost, we are not where we need to be. My research agenda is to conduct patient-oriented research that advances our understanding of overuse of healthcare among older adults. With the collaboration of junior investigators and other mentees, I will conduct research to understand how health care systems reduce the harmful overuse of healthcare resources by their Medicare beneficiaries through their delivery of high quality primary care. In the last four years of my funded work, my team and I have come to recognize that there is not yet a comprehensive understanding of drivers of overuse at the levels of the patient, clinician, and system, and the most optimal points for interventions are not yet defined. We developed the Johns Hopkins Overuse Index which is an index of 20 procedures that can measure regional variation in the overuse of healthcare resource. The index has been useful as an outcome measure and has allowed us to demonstrate the beneficial impact of higher regional density of primary care doctors on reducing overuse both among Medicare beneficiaries and younger, commercially insured people. I seek to understand the mechanisms by which high quality primary care reduces overuse of resources in older adults through a mixed-methods evaluation of positively deviating health systems and through modeling components of primary care delivery with mediation analysis methods. I also aim to improve the decisions made in the care of older adults by addressing a fundamental problem: that unappreciated heterogeneity of treatment effect (HTE) contributes to overuse of healthcare in older adults. Older adults are at particularly high risk of overuse of healthcare; this is both a discrete subpopulation of all adults, and a population with great variation amongst itself. Contributors to this variation include physiological differences attributable to marked variances in the aging process across individuals that manifests as frailty or robustness, as well as differences that arise due to the degree of multimorbidity, older adults’ preferences regarding interventions, and their ability to engage in self-care. The second proposed set of projects will involve the development of methods and tools to help clinicians to communicate more clearly with each other and with patients on this topic. With use of Design Thinking methods and engagement of collaborators from our Department of Art as Applied to Medicine, I will develop a framework and visual tools to assist with clear communication on this topic.