(PQE3)A Statewide RCT to Reduce Use of Ineffective or Unproven Breast Cancer Care

描述（由申请人提供）：在公众舆论、同行和国会预算办公室的支持下，一些专业协会最近开始制定相对昂贵的手术的“前五名”名单，这些手术对通常订购的至少某些类别的患者没有提供有意义的益处。由美国内科医学委员会开发并被大多数主要医学专业协会所接受的明智选择（R）运动是最明显的例子。然而，这些列表的发展在多大程度上影响了医生或患者的行为，仍然是未知的。在本申请中，我们将使用威斯康星州医疗质量合作组织（WCHQ），一个全州范围的医院、医疗实践和卫生系统联盟，作为一个实验室，检查两种组织干预措施的有效性：（i）“基本”公共报告干预措施，在公共网站上总结关于使用针对乳腺癌的无效或未经证实的干预措施的实践统计数据，以及（ii）“增强型”干预，通过基于智能手机的应用程序（App）增强公共报告，为提供者提供及时的信息、决策工具和个性化的患者教育材料，支持减少基于选择明智（R）或国家肿瘤学会指南的乳腺癌干预措施的使用。具体而言，我们的目标是：（1）使用Marketscan和Medicare索赔数据，同时调整可能的混杂因素和时间趋势，检查基本公共报告是否减少了干预状态下发生乳腺癌的当代患者队列中靶向乳腺癌实践的使用。(2)为了检查的有效性，加强干预相对于基本的干预，使用集群随机设计应用于WCHQ供应商;（3）为了模拟节省成本即将从全国范围内实施的两种干预措施（相对于对方和通常的护理），并描述这些发现的影响，报销政策和计划的举措。研究结果将提供严格的证据，证明一个独特的全付款人、全年龄段的公共报告系统的有效性，该系统可能会出口到其他州，并提供严格的证据，证明一种新的方法（应用程序）可以影响供应商的行为。这些结果对于所有对减少无效或未经证实的医疗服务的挑战感兴趣的人都很重要，包括政府，政策制定者，支付者，医疗服务提供者和消费者。结果将进一步相关的ACO环境，这是预计提供财政抑制提供无效或未经证实的护理。

DESCRIPTION (provided by applicant): Challenged by public opinion, peers and the Congressional Budget Office, a number of specialty societies have recently begun to develop "Top Five" lists of relatively expensive procedures that do not provide meaningful benefit to at least some categories of patients for whom they are commonly ordered. The Choosing Wisely(R) campaign, developed by the American Board of Internal Medicine and embraced by most of the major medical specialty societies, is the most visible example. The extent to which the development of these lists has influenced the behavior of physicians or patients, however, remains unknown. In this application, we will use the Wisconsin Collaborative for Healthcare Quality (WCHQ), a statewide consortium of hospitals, medical practices, and health systems, as a laboratory in which to examine the effectiveness of two organizational interventions: (i) a "basic" public reporting intervention which summarizes on a public website practice-level statistics regarding use of targeted ineffective or unproven interventions for breast cancer and (ii) an "enhanced" intervention, augmenting public reporting with a smart phone-based application (App) that gives providers just-in-time information, decision-making tools, and personalized patient education materials that support reductions in the use of breast cancer interventions targeted based upon Choosing Wisely(R) or national oncology society guidelines. Specifically, our aims are: (1) To examine whether basic public reporting reduces use of targeted breast cancer practices among a contemporary cohort of patients with incident breast cancer in the intervention state relative to usual care in comparison states, using Marketscan and Medicare claims data while adjusting for possible confounders and temporal trends. (2) To examine the effectiveness of the enhanced intervention relative to the basic intervention using a cluster-randomized design applied to WCHQ providers; and (3) To simulate cost savings forthcoming from nationwide implementation of both interventions (relative to each other and to usual care) and to describe the implications of these findings for reimbursement policy and program initiatives. The results will provide rigorous evidence regarding the effectiveness of a unique all-payer, all-age public reporting system that is potentially exportable to other states, a well as rigorous evidence regarding a novel method (App) for influencing provider behavior. The results will be important for all interested in the challenges of reducing ineffective or unproven care, including government, policy-makers, payers, health care providers, and consumers. The results will be further relevant to the ACO environment, which is expected to provide financial disincentives for providing ineffective or unproven care.