Strategies to Reduce Unnecessary Noninvasive Imaging

减少不必要的无创成像的策略

• 批准号: 10305698
• 负责人: David E Winchester
• 金额: --
• 依托单位: VETERANS HEALTH ADMINISTRATION
• 依托单位国家: 美国
• 财政年份: 2017
• 资助国家: 美国
• 起止时间: 2017-10-01 至 2024-09-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10305698
• 关键词: Address; Adopted; Adoption; Adverse effects; Attention; Award; Blinded; Capital; Cardiology; Caring; Clinical; Computer software; Computerized Patient Records; Cost Savings; Costs and Benefits; Data; Decision Support Systems; Diagnostic; Diagnostic Imaging; Diagnostic radiologic examination; Diagnostic tests; Direct Costs; Discipline of Nuclear Medicine; Echocardiography; Effectiveness; Feedback; Funding; Future; Glean; Goals; Habits; Health Services; Health Services Accessibility; Health system; Image; Interview; Investigation; Investigator-Initiated Research; Investments; Leadership; Learning; Literature; Magnetic Resonance Imaging; Malignant Neoplasms; Measures; Medical Societies; Medical center; Methods; Modality; Modeling; Motion; Odds Ratio; Patient Care; Patients; Practical Robust Implementation and Sustainability Model; Process; Program Reviews; Provider; Radiation; Radiology Specialty; Reporting; Research; Research Personnel; Research Project Grants; Risk; Series; Services; Single-Payer System; Strategic Planning; Structure; Surveys; System; Test Result; Testing; Theoretical Domains framework; Time; Translating; United States; United States Department of Veterans Affairs; Veterans; Veterans Health Administration; Wait Time; X-Ray Computed Tomography; administrative database; base; care delivery; career; cost; data streams; diaries; effectiveness evaluation; effectiveness measure; experience; health care delivery; human capital; implementation evaluation; implementation process; implementation science; implementation tool; improved; innovation; insight; microcosting; non-invasive imaging; noninvasive diagnosis; payment; point of care; primary outcome; programs; radiation risk; research clinical testing; support tools; ultrasound

Background: Patients undergo millions of noninvasive diagnostic imaging tests, including computed tomography, magnetic resonance imaging, and nuclear medicine, in the United States annually. Based on Appropriate Use Criteria (AUC) developed by professional medical societies, 20-30% of these tests may be inappropriate, i.e., the potential benefit-to-risk ratio is not maximized. Limited data on appropriateness of imaging within the Veterans Health Administration (VHA) suggests that inappropriate use is similar to that outside the VHA. A variety of methods have been employed to encourage more appropriate use of noninvasive imaging. One of the most popular is an electronic decision support tool (DST). These software products are added to patient care workflows to capture meaningful AUC data and reduce unnecessary testing. A recent VHA Evidence Synthesis Program (ESP) report concluded that little is known about the implementation of DSTs and possible negative ramifications of their use. Further, the cost to the VHA of noninvasive imaging testing, which has not been calculated, is needed to determine the burden of inappropriate tests. Specific Aims: In the course of this award, we will achieve the following specific aims: (1) assess potential barriers and facilitators to successful adoption of a DST, (2) determine the effectiveness of a DST using a stepped implementation process, and (3) estimate the fiscal effectiveness of a DST in the VA health system by developing a micro-costing model for delivery of noninvasive imaging tests. Significance: Through these investigations, we will glean valuable insight into how to adjust processes to improve the ordering of millions of costly tests. If effective at reducing unnecessary tests, the results from this proposal will ultimately improve Veterans' access to care and reduce radiation risks. Innovation: Study of DSTs has focused primarily on effectiveness, with little attention paid to the implementation process and possible adverse effects such as provider dissatisfaction and inefficiency. Our investigations will break new ground in studying these aspects of DSTs. The use of qualitative and micro- costing methods as we propose is innovative given their underuse for clinically oriented research. Methods: We will apply the Practical Robust Implementation and Sustainability Model (PRISM) and Theoretical Domains Framework (TDF) to the specific aims for this award. In Specific Aim 1, we will use qualitative and quantitative methods to identify possible barriers and facilitators to DST implementation through interviews and surveys of providers who order noninvasive tests. In Specific Aim 2, implementation of a DST for noninvasive imaging will be assessed from the rate of testing, the proportion of testing that is inappropriate, and feedback from providers in three discrete steps. First, providers blinded to AUC for imaging tests will order tests as usual. Second, at the point of ordering, they will receive immediate feedback on appropriateness of the test and be given the option to change the order. Third, if the provider's decision is not consistent with AUC, the provider will be required to give a justification for the test order. These steps will help us understand the implementation process for DSTs and to address gaps in the literature raised by the recent ESP. In Specific Aim 3, the cost of noninvasive imaging tests will be calculated using information from administrative databases, time-and-motion observation of care delivery, and cost diaries from Veterans. Expected Results: We anticipate that through these investigations, we will learn and be able to share important lessons about implementation of a DST for noninvasive imaging. The results will be the basis for investigator initiated research grants on further spread of DSTs within the VA system and adaptation to other imaging/testing modalities such as echocardiography.

背景：患者接受数百万个非侵入性诊断成像测试，包括计算 每年在美国，层析成像，磁共振成像和核医学。基于 专业医学社会开发的适当使用标准（AUC）可能是这些测试中有20-30％ 不当，即潜在的利益风险比没有最大化。关于适当性的数据有限 退伍军人卫生管理局（VHA）中的成像表明，不当使用类似 在VHA外面。已经采用了多种方法来鼓励更适当地使用无创 成像。最受欢迎的是电子决策支持工具（DST）。这些软件产品是 添加到患者护理工作流程中以捕获有意义的AUC数据并减少不必要的测试。最近 VHA证据综合计划（ESP）报告得出结论，对实施的实施知之甚少 DST和可能对其使用的负面影响。此外，无创成像的VHA的成本 尚未计算的测试需要确定不适当测试的负担。 具体目的：在本奖项的过程中，我们将实现以下特定目标：（1）评估潜在 成功采用DST的障碍和促进者，（2）确定DST的有效性 逐步实施过程，以及（3）估计DST在VA卫生系统中的财政效力 开发用于传递非侵入性成像测试的微型成本模型。 意义：通过这些调查，我们将了解如何调整过程的宝贵见解 改善数百万个昂贵测试的顺序。如果有效地减少了不必要的测试，则该测试的结果 提案最终将改善退伍军人获得护理的机会，并降低辐射风险。 创新：对DST的研究主要集中于有效性，很少关注 实施过程和可能的不利影响，例如提供者的不满和效率低下。我们的 研究将在研究DST的这些方面进行新的基础。使用定性和微型 鉴于它们在临床导向研究的不足之后，我们提出的成本核算方法是创新的。 方法：我们将应用实践强大的实施和可持续性模型（PRISM）和 理论领域框架（TDF）授予该奖项的具体目的。在特定目标1中，我们将使用 定性和定量方法，以确定通过 订购无创测试的提供者的访谈和调查。在特定目标2中，实施DST 对于非侵入性成像，将从测试速率中评估，这是不适当的测试比例 以及提供者的反馈，分为三个离散步骤。首先，对AUC视而不见的成像测试的提供商将订购 照常测试。其次，在订购时，他们将立即收到有关适当性的立即反馈 测试并可以选择更改订单的选项。第三，如果提供商的决定与 AUC，提供者将被要求为测试订单提供理由。这些步骤将帮助我们理解 DST的实施过程，并解决最近ESP提出的文献中的差距。在 具体目标3，将使用管理中的信息来计算非侵入性成像测试的成本 数据库，护理交付的时间和动作观察以及退伍军人的成本日记。 预期结果：我们预计通过这些调查，我们将学习并能够分享 关于实施非侵入成像的DST的重要经验教训。结果将是 研究人员启动了有关DST在VA系统中进一步传播的研究，并适应了其他 成像/测试方式，例如超声心动图。