De-Implementation of Low Value Imaging in Pulmonary Embolism (DELVE PE)

1个项目摘要 2在美国每年1.2亿人次的急诊科就诊中，有2%(2%)的患者接受了 每年进行3次肺血管断层扫描(CTPA)诊断肺栓塞(PE)。然而，其中许多都是 4.可以避免。不必要的检查使患者面临额外的费用、电离辐射和对比剂过敏反应的风险。 5个媒体。此外，由于假阳性CTPA很常见(估计为5%-26%)，过度诊断和过度治疗 6美国的问题越来越多。尽管指南建议减少对PE的低价值成像，但 7美国急诊室不必要的PE成像研究数量继续上升，使患者暴露在过度检测和 8过度诊断。以前的策略曾试图缩小这种知识-实践质量差距，但只取得了不大的成功， 9可能是因为改变提供商的行为具有挑战性，而且大多数计划都集中在孤立的战略上。我们建议 10制定、试行和评估多层面的“强化”审计反馈战略(EAF)，以消除低价值 11在PE中进行成像。核心战略，审计反馈，被选为针对在年发现的PE中低价值成像的驱动因素 12我们的基础工作：知识、同辈压力、情感和对后果的信念。我们设计的策略是使用 13提出了一种新的审计反馈理论--临床绩效反馈干预理论(CP-FIT)。审计反馈是 14通过补充战略“加强”，以协助行动规划并增强临床医生改变其行为的能力。这 15包括用于指导临床医生通过用于评估PE的明确算法进行适当测试的辅助工具，以及 16个教育播客和本地冠军。在目标1中，我们将制定、完善和实施取消实施 17个战略组成部分。我们将对审计反馈报告的原型进行认知测试，制定 18电子健康记录(EHR)-综合援助，录制教育播客，识别和培训当地冠军。在……里面 19目标2，我们将在5个ED试行EAF战略的替代版本，以评估可接受性和适当性。我们 20将改变反馈部分的交付(本地冠军与部门主席)、教育播客(带 21或没有真实的患者描述)，以及适当测试的辅助(静态与EHR集成辅助)，以确定 22这些迭代的可接受性、适当性和附加值。我们将试行不同版本的战略以进行评估 CP-FIT的23个方面，包括复杂性、社会影响力和可操作性，CP-FIT建议推动审计反馈 24个周期，最终，行为改变。我们将使用混合方法对该战略进行评估，并选择一个精细化的战略 25多中心试验。在这份K23申请中，我们提出了一份详细的职业发展计划，我将在其中受益 26在高级执行科学战略、方法和试验设计方面的方法学和技术专长。我很好 27由经验丰富的导师和顾问团队提供支持。在这个指导职业发展奖结束时，我将 28个拥有强大的经验派生和理论知识的战略，并将在多中心测试这一战略 29以独立调查员的身份进行审判。 30

1 PROJECT SUMMARY 2 Two percent (2%) of all 120 million annual emergency department (ED) visits in the United States undergo computed 3 tomographic pulmonary angiography (CTPA) for pulmonary embolism (PE) every year. However, many of these are 4 avoidable. Unnecessary testing subjects patients to additional costs, ionizing radiation, and risk of anaphylaxis from contrast 5 media. Further, because false positive CTPAs are common (estimated at 5-26%), overdiagnosis and overtreatment are 6 growing problems in the United States. Despite guidelines recommending the reduction of low-value imaging for PE, the 7 volume of unnecessary imaging studies for PE in US EDs continues to rise, exposing patients to harm from overtesting and 8 overdiagnosis. Prior strategies have attempted to close this knowledge-practice quality gap but only had modest success, 9 possibly because changing provider behavior is challenging and most initiatives focused on isolated strategies. We propose 10 to develop, pilot, and evaluate a multi-dimensional `enhanced' audit-feedback strategy (EAF) to de-implement low-value 11 imaging in PE. The core strategy, audit-feedback, was chosen to target drivers of low-value imaging in PE discovered in 12 our foundational work: knowledge, peer pressure, emotion, and belief about consequences. We designed the strategy using 13 a novel audit-feedback theory, the Clinical Performance Feedback Intervention Theory (CP-FIT). The audit-feedback is 14 `enhanced' by complementary strategies to assist in action planning and empower clinicians to change their behavior. This 15 includes an aid for appropriate testing that guides clinicians through an unambiguous algorithm for evaluation of PE, an 16 educational podcast, and local champions. In Aim 1, we will develop, refine, and operationalize the de-implementation 17 strategy components. We will conduct cognitive testing of the prototypes of the audit-feedback reports, develop an 18 electronic health record (EHR)-integrated aid, record the educational podcast, and identify and train local champions. In 19 Aim 2, we will pilot alternative versions of the EAF strategy in 5 EDs to evaluate acceptability and appropriateness. We 20 will alter the delivery of the components of feedback (local champion versus departmental chair), educational podcast (with 21 or without a real patient narrative), and the aid for appropriate testing (static versus EHR-integrated aid) to ascertain the 22 acceptability, appropriateness, and added value of these iterations. We will pilot different versions of the strategy to evaluate 23 aspects of CP-FIT including complexity, social influence, and actionability, which CP-FIT suggests drive the audit-feedback 24 cycle and, ultimately, behavior change. We will use mixed methods to evaluate the strategy and select a refined strategy for 25 a multi-center trial. In this K23 application, we have proposed a detailed career development plan in which I will gain 26 methodological and technical expertise in advanced implementation science strategies, methods, and trial design. I am well 27 supported by an experienced team of mentors and advisors. At the end of this mentored career development award, I will 28 have a robust empirically-derived and theory-informed strategy and will be positioned to test this strategy in a multi-center 29 trial as an independent investigator. 30