Combining Policy and Implementation Science to Optimize Clinical Practice

PROJECT SUMMARY ABSTRACT: Changing clinician practice is difficult but important. Traditionally, strategies to attain sustainable practice change have followed one of two general paths: financial incentives and practice redesign and implementation. Financial incentives, while often effective in aggregate, tend to have heterogeneous effects across individuals and systems. Practice design and implementation, while allowing for highly tailored local solutions, is resource intensive and thus difficult to scale across settings and populations. We hypothesize that the two strategies can be deployed together, augmenting their respective strengths and mitigating their weaknesses. The Principal Investigator, in her ongoing K08-award, identified preoperative patient optimization as an ideal case study for new models effecting clinician practice change. Adherence to best practices that manage obesity, smoking, and diabetes preoperatively can reduce surgical complications by up to 40%. Despite the compelling clinical case, surgeon adherence to preoperative patient optimization remains surprisingly low. Her work highlighted the most important barriers to surgeon adherence. First, surgeons have little financial incentive to delay surgery, suggesting the potential for financial incentives to quickly align surgeon practices with patient preoperative optimization. Second, barriers related to resources for patient optimization, organizational culture, and established practice patterns were identified; highlighting the need for additional behavior change strategies such as a clinician facing educational and behavior change intervention PREoperative Program (PREP) and onsite facilitation to overcome organizational and practice barriers. This proposal builds on these K08 findings to deploy and test a novel combination of: 1) a policy creating a financial incentive (policy evaluation) with 2) implementation science strategies (by adding these resources to policy non-responders) to create an effective and scalable program to improve practice. The project will leverage the Michigan Surgical Quality Collaborative (MSQC), a well-established, statewide registry and improvement consortium involving 70 hospitals in Michigan. We will take advantage of a unique opportunity to conduct a natural experiment of a recently launched pay-for-performance (P4P) program (Aim 1) combined with a non-responder Sequential Multiple Assignment Randomized Trial (SMART) trial (Aims 2 and 3) to test the effectiveness of PREP and an onsite facilitator on augmenting site underperformance or non- response to the P4P incentive. The SMART design allows for testing a strategy of applying higher resource intervention only when the change was not facilitated with a lower resource intervention, explicitly recognizing the trade-off between resource intensity and scalability. The proposed study will have immediate and significant impact by developing and validating optimal strategies for improving adherence to patient optimization across a statewide health system. More broadly, the project will inform novel adaptive implementation strategies that could be scaled to other important practice gaps.