Identifying Areas to Improve ICU Outcomes through Provider Variation

项目总结/摘要 每年有超过100万美国人需要机械通气，死亡率估计在30-35%之间 在患者、医院和区域水平上具有显著的可变性。最近，医生们被发现 与机械通气患者的死亡率相关，增加了另一个水平的变化。几乎没有 研究个体医生做什么导致这种结果的变化，以及提供者的做法是否 可以修改模式以改善结果。迄今为止，在这方面采取的降低发病率和死亡率的干预措施 人群涉及通气策略和减少伤害治疗。尽管这些干预措施 尽管这些方法以证据为基础，并得到准则的支持，但其使用情况仍然存在很大差异。之间的潜在联系 在循证实践中，提供者水平的死亡率变异和人群水平的变异代表了 关键的知识差距。具体来说，有必要了解医生如何坚持证据- 基于不同的实践，这导致伤害的程度，以及什么障碍正在改变实践 模式.候选人先前的工作开发了一种方法，使用电子健康记录元数据， 为每个重症监护日的每位患者提供回顾性和可靠的服务。使用这些数据，供应商- 坚持低潮气量通气策略的水平在12家医院的健康状况中存在显著差异。 系统这个职业发展奖建立在这项工作，并寻求实现三个目标，即在一起， 将促进候选人的长期目标，即开发和测试策略，以提高对 循证护理和改善急性呼吸衰竭幸存者的结果。具体来说，在这个奖项中， 候选人寻求（1）量化遵守循证实践的医生之间的差异，（2） 产生关于循证实践坚持的障碍和促进因素的假设，以及（3）制定和 试点针对循证护理障碍的干预措施。为了实现这些目标，候选人将 进行回顾性队列研究（目标1），进行混合方法研究，招募40名基于病房的 护理机械通气患者的医生（目标2），并使用干预映射框架， 制定并试行针对低潮气量通气障碍的干预措施。他的亲身体验 将获得在完成这三个研究使用不同的方法将得到补充， 选定的教学课程和来自多个学科的高级调查员的结构化指导。这 工作将导致试点赠款和R 01，以支持这种干预的随机临床试验。完成本 研究将建立在候选人的过去的培训，并将为他提供保护的时间， 经验，以实现他的职业目标，成为一个领先的，独立资助的成果研究员 重点是在学习卫生系统内进行研究，以改善ARF幸存者的结局 和其他严重疾病。

PROJECT SUMMARY/ABSTRACT Over 1 million Americans require mechanical ventilation each year and mortality estimates range from 30-35% with significant variability at the patient, hospital, and regional level. More recently, physicians were found to be associated with mortality in mechanically ventilated patients, adding yet another level of variation. There is little research as to what individual physicians do to cause this variation in outcomes and whether provider practice patterns can be modified to improve outcomes. To date, morbidity and mortality reduction interventions in this population involve ventilation strategies and harm reduction therapies. Despite these interventions being evidence-based and guideline-supported, their use remains highly variable. The potential link between provider-level variability in mortality and population-level variation in evidence-based practice represents a critical knowledge gap. Specifically, there is a need to understand how physicians’ adherence to evidence- based practices vary, the degree to which this results in harm, and what barriers are modifying practice patterns. The candidate's prior work developed a method, using electronic health record metadata, to assign a provider retrospectively and reliably to each patient for each intensive care day. Using these data, provider- level adherence to low tidal volume ventilation strategies significantly varied across a 12-hospital health system. This Career Development Award builds from that work and seeks to achieve three aims, that together, will promote the candidate's long-term goal of developing and testing strategies to increase adherence to evidence-based care and improve acute respiratory failure survivors' outcomes. Specifically, in this award, the candidate seeks to (1) quantify variation among physicians in adherence to evidence-based practices, (2) generate hypotheses about barriers and facilitators to evidence-based practice adherence, and (3) develop and pilot an intervention targeting barriers to evidence-based care. To complete these aims the candidate will perform a retrospective cohort study (Aim 1), perform a mixed-method study enrolling 40 ward-based physicians that care for mechanically ventilated patients (Aim 2), and use an intervention mapping framework to develop and pilot an intervention targeting barriers to low tidal volume ventilation. The hands-on experience he will acquire in completing these three studies using different methods will be complemented by carefully selected didactic coursework and structured mentoring by senior investigators from multiple disciplines. This work will lead to pilot grants and R01 to support a randomized clinical trial of this intervention. Completing this research will build upon the candidate’s past training and will provide him with the protected time and experience to achieve his career goal of becoming a leading, independently funded outcomes researcher focused on conducting studies within learning health systems to improve outcomes among survivors of ARF and other critical illnesses.