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：患者接受数百万次无创诊断成像测试，包括计算机 每年在美国进行断层扫描、磁共振成像和核医学。基于 由专业医学会制定的适当使用标准（AUC），这些测试中的 20-30% 可能是 不适当，即潜在的收益风险比没有最大化。关于适当性的数据有限 退伍军人健康管理局 (VHA) 内的成像表明，不当使用类似于 VHA 之外。已采用多种方法来鼓励更适当地使用非侵入性 成像。最流行的工具之一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。最近的一个 VHA 证据综合计划 (ESP) 报告的结论是，人们对于该计划的实施知之甚少 夏令时及其使用可能产生的负面影响。此外，无创成像的 VHA 成本 需要进行尚未计算的测试来确定不适当测试的负担。 具体目标：在本次获奖过程中，我们将实现以下具体目标：（1）评估潜力 成功采用 DST 的障碍和促进因素，(2) 使用以下方法确定 DST 的有效性： 分步实施流程，以及 (3) 通过以下方式估计 VA 卫生系统中 DST 的财政有效性： 开发用于无创成像测试的微观成本计算模型。 意义：通过这些调查，我们将收集关于如何调整流程以适应变化的宝贵见解。 改进数百万次昂贵测试的排序。如果能有效减少不必要的测试，那么结果 该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：DST的研究主要关注有效性，而很少关注其效果 实施过程和可能的不利影响，例如提供商不满意和效率低下。我们的 调查将为研究 DST 的这些方面开辟新天地。使用定性和微观 我们提出的成本计算方法是创新的，因为它们在面向临床的研究中并未得到充分利用。 方法：我们将应用实用稳健实施和可持续性模型（PRISM）和 理论领域框架（TDF）体现了该奖项的具体目标。在具体目标 1 中，我们将使用 通过定性和定量方法来确定夏令时实施中可能的障碍和促进因素 对订购无创检测的提供者进行访谈和调查。在具体目标 2 中，实施 DST 对于无创成像，将根据测试率、不适当的测试比例进行评估， 并通过三个独立步骤获得提供商的反馈。首先，对影像学测试 AUC 不知情的提供商将订购 像往常一样进行测试。其次，在订购时，他们将立即收到有关产品是否合适的反馈。 测试并可以选择更改顺序。第三，如果提供者的决定与 AUC，提供商将被要求给出测试订单的理由。这些步骤将帮助我们理解 DST 的实施过程并解决最近 ESP 提出的文献中的空白。在 具体目标 3，将使用行政部门的信息来计算无创成像测试的成本 数据库、护理服务的时间和动作观察以及退伍军人的费用日记。 预期结果：我们预计通过这些调查，我们将了解并能够分享 关于实施无创成像 DST 的重要经验教训。结果将作为基础 研究人员发起了研究资助，以进一步在 VA 系统内推广 DST 并适应其他系统 成像/测试方式，例如超声心动图。