Combining Policy and Implementation Science to Optimize Clinical Practice

项目总结摘要：改变临床医生的做法是困难的，但很重要。传统上， 实现可持续实践变革的战略遵循两条一般路径之一：财政激励 实践重新设计和实施。财政激励措施虽然在总体上往往是有效的， 对个体和系统的异质性影响。实践设计和实施，同时考虑到 高度定制的地方解决方案是资源密集型的，因此难以在不同环境和人群中推广。 我们假设这两种策略可以一起部署，增强各自的优势， 减轻他们的弱点。主要研究者在她正在进行的K 08奖中，确定了术前 患者优化作为影响临床实践变化的新模型的理想案例研究。遵守 术前控制肥胖、吸烟和糖尿病的最佳实践可以减少手术并发症 高达40%。尽管有令人信服的临床病例，外科医生坚持术前患者优化 仍然出奇的低。她的工作突出了外科医生依从性的最重要障碍。第一、 外科医生没有什么经济动机来推迟手术，这表明经济动机的潜力， 快速调整外科医生实践与患者术前优化。第二，与资源有关的障碍， 确定了患者优化、组织文化和既定的实践模式;强调了 需要额外的行为改变策略，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 隔栏.该提案建立在这些K 08发现的基础上，以部署和测试以下新组合：1）政策 建立一个财政激励机制（政策评估），2）实施科学战略（通过增加这些 资源的政策无反应者），以创建一个有效的和可扩展的计划，以改善实践。的 该项目将利用密歇根州外科质量协作（MSQC），一个完善的，全州范围内的注册 以及密歇根州70家医院的改善联盟。我们将利用一个独特的 有机会对最近推出的按绩效付费（P4P）计划进行自然实验（目标1） 与无应答者序贯多重分配随机试验（SMART）试验（目的2和 3)测试PREP和现场辅导员在改善现场表现不佳或不佳方面的有效性， 对P4P激励的回应。SMART设计允许测试应用更高资源的策略 只有在变革没有得到较低资源干预的推动时才进行干预，明确认识到 资源密集度和可扩展性之间的权衡。拟议的研究将立即并 通过开发和验证改善患者依从性的最佳策略， 优化整个国家的卫生系统。更广泛地说，该项目将告知新的适应性 可以根据其他重要的实践差距调整实施战略。

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.