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

肺栓塞低价值成像的取消实施 (DELVE PE)

基本信息

批准号：
10302031
负责人：
Lauren Westafer
金额：
$ 17.43万
依托单位：
BAYSTATE MEDICAL CENTER, INC.
依托单位国家：
美国
项目类别：
财政年份：
2021
资助国家：
美国
起止时间：
2021-09-01 至 2026-07-31
项目状态：
未结题

来源：
https://reporter.nih.gov/project-details/10302031
关键词：
Accident and Emergency department Address Administrator Advisory Committees Algorithms American American College of Radiology Anaphylaxis Angiography Area Behavior Belief Benchmarking Caring Chest Clinical Clinical Oncology Supplement (K12)Communities Data Deimplementation Department chair Development Plans Dyes Effectiveness Electronic Health Record Elements Emergency Department Physician Emergency Medicine Emergency department visit Emotions Ensure Evaluation Evidence based practice Feedback Foundations Fright Goals Guidelines Health system Image Informatics Institution Intervention Interview Investigation Ionizing radiation K-Series Research Career Programs Knowledge Learning Module Lung Massachusetts Mentored Patient-Oriented Research Career Development Award Mentors Methodology Methods Multicenter Trials National Heart, Lung, and Blood Institute Patient Care Patients Peer Pressure Performance Physicians Pilot Projects Positioning Attribute Provider Pulmonary Embolism Reporting Research Research Personnel Risk Safety Societies Structure Surveys Technical Expertise Testing Training United States Work X-Ray Computed Tomography base behavior change career development clinical decision support cognitive testing college cost design evidence base experience imaging study implementation barriers implementation facilitators implementation framework implementation science implementation strategy improved innovation insight lung imaging novel organizational climate overtreatment podcast practice setting prototype provider behavior radiation risk risk stratification social success theories tomography tool trial design usability user centered design

项目摘要

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

1 项目概要 2 美国每年 1.2 亿急诊科 (ED) 就诊次数中的百分之二 (2%) 接受了计算每年 3 次肺栓塞 (PE) 断层肺血管造影 (CTPA)。然而，其中许多都是 4 可避免的。不必要的测试会使患者承担额外费用、电离辐射以及造影剂过敏反应的风险 5 媒体。此外，由于 CTPA 假阳性很常见（估计为 5-26%），过度诊断和过度治疗也很常见。美国日益严重的 6 个问题。尽管指南建议减少 PE 的低价值成像，但 7 美国急诊室中不必要的 PE 影像学研究数量持续增加，使患者面临过度检测和 8.过度诊断。先前的策略曾试图缩小这种知识与实践质量差距，但只取得了一定的成功， 9 可能是因为改变提供商的行为具有挑战性，而且大多数举措都侧重于孤立的策略。我们建议 10 制定、试点和评估多维“增强”审计反馈策略（EAF），以消除低价值 11 PE 成像。选择审计反馈这一核心策略来针对 PE 中发现的低价值成像驱动因素。 12 我们的基础工作：知识、同伴压力、情感和对后果的信念。我们设计的策略使用 13 一种新颖的审核反馈理论，临床表现反馈干预理论（CP-FIT）。审核反馈为 14 通过补充策略“增强”，以协助行动规划并授权临床医生改变其行为。这 15 包括适当测试的辅助工具，指导临床医生通过明确的算法来评估 PE， 16 个教育播客和当地冠军。在目标 1 中，我们将开发、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，开发一个 18 电子健康记录 (EHR) 集成援助，录制教育播客，并识别和培训当地冠军。在 19 目标 2，我们将在 5 个征求意见稿中试点渔业生态系统方法战略的替代版本，以评估可接受性和适当性。我们 20 将改变反馈组成部分的提供（当地冠军与部门主席）、教育播客（与 21 或没有真实的患者叙述），以及进行适当测试的援助（静态援助与 EHR 综合援助）以确定 22 这些迭代的可接受性、适当性和附加值。我们将试点不同版本的策略来评估 CP-FIT 的 23 个方面，包括复杂性、社会影响力和可操作性，CP-FIT 建议推动审核反馈 24 循环，最终导致行为改变。我们将使用混合方法来评估策略并选择细化策略 25 一项多中心试验。在这次K23申请中，我们提出了详细的职业发展计划，我将在其中获得 26 种先进实施科学策略、方法和试验设计方面的方法和技术专业知识。我很好 27 由经验丰富的导师和顾问团队提供支持。在这个指导性职业发展奖结束时，我将 28 拥有稳健的基于经验和理论的策略，并将在多中心测试该策略 29 作为独立调查员进行试验。 30