Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.
J Gen Intern Med. 2019 Sep;34(9):1857-1864. doi: 10.1007/s11606-019-05069-5. Epub 2019 Jun 27.
Studies of interventions to reduce low-value care are increasingly common. However, little is known about how the effects of such interventions are measured.
To characterize measures used to assess interventions to reduce low-value care.
We searched PubMed and Web of Science to identify studies published between 2010 and 2016 that examined the effects of interventions to reduce low-value care. We also searched ClinicalTrials.gov to identify ongoing studies. We extracted data on characteristics of studies, interventions, and measures. We then developed a framework to classify measures into the following categories: utilization (e.g., number of tests ordered), outcome (e.g., mortality), appropriateness (e.g., overuse of antibiotics), patient-reported (e.g., satisfaction), provider-reported (e.g., satisfaction), patient-provider interaction (e.g., informed decision-making elements), value, and cost. We also determined whether each measure was designed to assess unintended consequences.
A total of 1805 studies were identified, of which 101 published and 16 ongoing studies were included. Of published studies (N = 101), 68% included at least one measure of utilization, 41% of an outcome, 52% of appropriateness, 36% of cost, 8% patient-reported, and 3% provider-reported. Funded studies were more likely to use patient-reported measures (17% vs 0%). Of ongoing studies (registered trials) (N = 16), 69% included at least one measure of utilization, 75% of an outcome, 50% of appropriateness, 19% of cost, 50% patient-reported, 13% provider-reported, and 6% patient-provider interaction. Of published studies, 34% included at least one measure of an unintended consequence as compared to 63% of ongoing studies.
Most published studies focused on reductions in utilization rather than on clinically meaningful measures (e.g., improvements in appropriateness, patient-reported outcomes) or unintended consequences. Investigators should systematically incorporate more clinically meaningful measures into their study designs, and sponsors should develop standardized guidance for the evaluation of interventions to reduce low-value care.
减少低价值医疗的干预措施研究越来越普遍。然而，对于此类干预措施的效果如何衡量，人们知之甚少。
描述用于评估减少低价值医疗干预措施的措施。
我们在 PubMed 和 Web of Science 上搜索了 2010 年至 2016 年期间发表的研究，这些研究考察了减少低价值医疗的干预措施的效果。我们还在 ClinicalTrials.gov 上搜索了正在进行的研究。我们提取了研究、干预措施和措施特征的数据。然后，我们开发了一个框架，将措施分为以下几类：利用（例如，测试数量）、结果（例如，死亡率）、适当性（例如，抗生素滥用）、患者报告（例如，满意度）、提供者报告（例如，满意度）、患者-提供者互动（例如，知情决策要素）、价值和成本。我们还确定了每个措施是否旨在评估意外后果。
共确定了 1805 项研究，其中 101 项已发表，16 项正在进行。已发表的研究（N=101）中，68%的研究至少包含一项利用措施，41%的研究包含一项结果，52%的研究包含适当性，36%的研究包含成本，8%的研究包含患者报告，3%的研究包含提供者报告。有资金支持的研究更有可能使用患者报告的措施（17%比 0%）。正在进行的研究（注册试验）（N=16）中，69%的研究至少包含一项利用措施，75%的研究包含一项结果，50%的研究包含适当性，19%的研究包含成本，50%的研究包含患者报告，13%的研究包含提供者报告，6%的研究包含患者-提供者互动。与正在进行的研究（63%）相比，已发表的研究中有 34%的研究至少包含一项意外后果的措施。
大多数已发表的研究侧重于减少利用，而不是更有临床意义的措施（例如，适当性的提高、患者报告的结果）或意外后果。研究人员应在其研究设计中系统地纳入更有临床意义的措施，赞助商应为减少低价值医疗干预措施的评估制定标准化指南。
