Providing appropriate health care means ensuring that patients get the care they need while avoiding care that is unnecessary or harmful. In the 1990s, VHA's first transformation focused on increasing the use of necessary services through a performance management system that has become a panoply of guidelines, performance measures, reminders, registries, and incentives. As a result, the underuse of necessary services in VHA decreased dramatically. Today, there is growing interest in identifying overuse - care that exposes patients to services that are not beneficial or may cause harm and which may take scarce resources away from those who would benefit from them. The national Choosing Wisely campaign is one manifestation of this trend. While this campaign has garnered attention, it has not produced systematic or reproducible approaches to identify overuse. Within the general realm of overuse, a more focused target is promoting de-intensification when good quality practice calls for decreasing the intensity or frequency of medical services that are currently part of a patient's ongoing management. Increasingly, we recognize that care is too frequent or too intensive in cases where the marginal benefit is absent or there is potential for patient harm, and that both providers and patients have particular difficulty stopping routine testing and treatments once they have successfully become part of a patient's regular care. One example is intensive glycemic management among diabetic patients who are elderly or have major comorbidities. Yet, most quality monitoring and improvement initiatives continue to provide largely unopposed incentives to escalate care intensity. The proposed study will: 1) identify and validate clinical indications for de-intensification in primary care (Aim 1); 2) assess the prevalence and reliabilit of measures of de-intensification in VHA (Aim 2); and 3) develop multi-level strategies to disseminate and implement de-intensification measures (Aim 3).
Aim 1 will involve an environmental scan to identify a preliminary list of potential de-intensification indications; a raid evidence synthesis of existing evidence supporting candidate de-intensification indications; a high level prevalence estimate of opportunities for de-intensification in VHA; and, expert panels to rate each of the potential indications on improvement opportunity, validity, and feasibility of measurement and implementation.
Aim 2 will include constructing measures of de-intensification indications and conducting an analysis to examine prevalence, variance, and reliability of measuring de-intensification in VHA.
AIM 3 will involve engaging providers, clinical managers, and patients in collaborative decision-making to develop an operational measurement procedure for disseminating and implementing the identified de-intensification measures. Findings from each of the Aims will be synthesized into practical intervention strategies. An advisory council, comprised of VHA and national policy, content and measurement experts, will work with the research team in all stages to review results and provide guidance on indication measurement prioritization, feasibility, implementation, and dissemination. Identifying, measuring, and understanding how to promote de-intensification - to complement the many measures promoting appropriate intensification - is critical to restoring balance to VHA's efforts to improve care quality. This study will develop a systematic method to identify when de-intensification is called for, assess how frequently de-intensification occurs in VHA, and provide approaches to reliably measure and deploy measures of de-intensification. The project is unique by involving all stakeholders, including clinical and policy experts, front-line providers, clinical leaders, and patients in developing an operational measurement procedure and implementation approach that can ensure reliable measurement, promote quality improvement, and avoid organizational dysfunction.
This study will develop a reproducible method to identify, validate, and reliably measure indications for de- intensification of medical services in primary care, ultimately decreasing unnecessary and potentially harmful care. This method could eventually be used to identify and validate a broad range of clinical measures and develop measurement deployment approaches on an ongoing basis in a comprehensive performance management system. Project products (in about year 1.5) will include: 1) a tested systematic process to identify and validate clinical indications and approaches for de-intensification; and 2) a set of validated indications that are packaged for use within both VHA and other healthcare systems. Later products will consist of: 3) a set of tracking measures of de-intensification for population management (with four measures prioritized for earlier assessment); and 4) a synthesized package of measurement deployment strategies that have been vetted by the providers and patients who will use them.
