Improving safety and quality through evidence-based de-implementation of ineffective diagnostics and therapeutics.

通过基于证据的无效诊断和治疗的取消实施来提高安全性和质量。

• 批准号: 10179483
• 负责人: David H Au
• 金额: --
• 依托单位: VA PUGET SOUND HEALTHCARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2015
• 资助国家: 美国
• 起止时间: 2015-10-01 至 2020-09-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10179483
• 关键词: Address; Adrenal Cortex Hormones; Antipsychotic Agents; Behavioral; Cardiac; Cardiology; Caring; Chronic Obstructive Airway Disease; Clinic; Clinical; Dementia; Diagnostic; Disease; Effectiveness; Etiology; Evaluation; Follow-Up Studies; Funding; Goals; Guidelines; Health Services Accessibility; Healthcare; Image; Improve Access; Inhalation; Investments; Knowledge; Long-Term Care; Lung nodule; Methods; Modeling; Myocardial perfusion; Patients; Perception; Pharmaceutical Preparations; Pneumonia; Policies; Procedures; Provider; Quality of Care; Radiation exposure; Recommendation; Resources; Risk; Safety; Science; Series; Services; Societies; Steroids; Stroke; Structure; Taxonomy; Testing; Therapeutic; Time; Veterans; Wait Time; Work; X-Ray Computed Tomography; base; budget impact; burnout; care delivery; care systems; clinical Diagnosis; clinical practice; compare effectiveness; effectiveness testing; evidence base; follow-up; formative assessment; health care delivery; implementation science; implementation strategy; improved; ineffective therapies; medical specialties; mortality risk; patient oriented; patient population; perfusion imaging; pharmacy benefit; programs; tool

 DESCRIPTION (provided by applicant): Project Background: According to IOM, high quality care is safe, effective and patient centered. Initiatives such as Choosing Wisely, a program to de-implement low value practices, can provide an effective message to simultaneously improve quality and value. However, while Choosing Wisely identifies targets for de-implementation, it does not speak to what strategies may help achieve this goal. While much is known about effective implementation strategies, little is known about effective de-implementation strategies. This is important because active de- implementation likely entails different dynamics, and unintended consequences, than implementation. VA operational partners in Pharmacy Benefits Management and Office of Specialty Care Services have helped identify and prioritize an initial set of common clinical practices that should be de-implemented. Project Objectives: Our overall goal is to improve healthcare delivery, safety and value for Veterans and VHA, consistent with multiple strategies outlined in the VA Blueprint for Excellence, by working with our partners in the Office of Specialty Care and Pharmacy Benefits Management to de-implement low value practices. We propose a series of experimental and quasi-experimental quality-improvement projects that compare the effectiveness of alternative de-implementation strategies: strategies based on changing clinician information and knowledge, and strategies based on providing tools and substitutes to the harmful practices. Our specific aims are to: Aim 1. Work with key operational leaders to identify and prioritize diagnostics and therapeutics that are ineffective, contraindicated, or of low value to patients, and develop de-implementation strategies that work in concert with operational strategies and policies. Aim 2. Test the effectiveness of de-implementation strategies to reduce ineffective, contraindicated or low value diagnostics and therapeutics. Aim 3. Develop the science and taxonomy of de-implementation by assessing the impact on de- implementation from (a) clinicians' perception of the evidence about ineffective practices, (b) clinicians' professional efficacy, and (c) clinics' organizational context. Aim 4. Assess the budget impact of de-implementation strategies in order to inform dissemination. Project Methods: We will test de-implementation strategies for four clinical practices spanning multiple specialties and patient populations, including both therapeutic and diagnostic practices. In each project, we will test the effectiveness of de-implementation strategies alone and in combination, and will assess the budget impact of fielding de- implementation strategies. Built on the structure of our successful and longstanding QUERI/Office of Specialty Care Evaluation Center, we will incorporate a mixed-methods formative evaluation to assess barriers and facilitators, and identify potential unintended consequences of the de-implementation strategies. We will assess changes, before and after employing de-implementation strategies in participating clinicians' perceptions of the empirical evidence against the ineffective practice; clinicians' intent to reduce the ineffective practice; and professional inefficacy (a component of work-related burnout). We will also assess key components of organizational context, such as culture of change among leaders and staff. We will assess organizational context as a moderator of de-implementation strategy effectiveness across clinical settings and practice changes. By doing this we will contribute to the science and taxonomy of de-implementation by developing, testing and refining a conceptual model of de-implementation.

 描述（由申请人提供）： 项目背景：根据IOM，高质量的护理是安全，有效且以患者为中心的。明智地选择诸如降低价值实践的计划之类的计划可以提供有效的信息，以简单地提高质量和价值。但是，尽管选择明智地识别去实施目标的目标，但它并不是说明哪些策略可能有助于实现这一目标。虽然对有效的实施策略知之甚少，但对有效的实施策略知之甚少。这很重要，因为主动去实施可能实体可能不同的动态和意想不到的后果，而不是实施。 VA药房福利管理和专业护理服务办公室的运营合作伙伴有助于确定并优先考虑一系列应取消实施的常见临床实践。项目目标：我们的总体目标是通过与我们在专业护理和药品福利管理办公室的合作伙伴合作以降低低价值实践的方式来改善退伍军人和VHA的医疗保健交付，安全性和价值，这与VA蓝图中概述的多种策略一致。我们提出了一系列实验和准实验质量改善项目，以比较替代性去实施策略的有效性：基于改变临床信息和知识的策略，以及基于为有害实践提供工具和替代品的策略。我们的具体目的是：目标1。与主要的运营领导者合作，确定并确定对患者无效，禁忌或价值较低的诊断和治疗的优先级，并制定与运营策略和政策协同作用的去实施策略。目标2。测试减少实施策略的有效性，以减少无效，禁忌或低价值的诊断和治疗疗法。目标3。通过评估（a）临床医生对有关无效实践的证据，（b）临床医生的专业效率以及（c）诊所组织环境的证据的看法，通过评估（a）临床医生对（a）临床医生对临床医生对证据的看法的影响来发展进行实施的科学和分类法。目标4。评估降级策略的预算影响以告知传播。项目方法：我们将针对跨越多个专业和患者人群的四种临床实践测试实施策略，包括治疗和诊断实践。在每个项目中，我们将单独和组合进行实施策略的有效性，并评估现场退化策略的预算影响。我们将建立在我们成功且长期存在的特殊护理评估中心办公室的结构上，我们将纳入混合方法的形成性评估，以评估障碍和促进者，并确定消除实施策略的潜在无意后果。我们将在采用降级策略前后评估参与临床医生对反对无效实践的经验证据的看法的变化；临床医生的意图减少无效的实践；专业无效（与工作有关的倦怠的组成部分）。我们还将评估组织环境的关键组成部分，例如领导者和员工之间的变化文化。我们将评估组织环境，作为跨临床环境和实践变化跨越实施策略有效性的主持人。通过这样做，我们将通过开发，测试和完善实施概念模型来为去实施的科学和分类法做出贡献。