Teaching high-value, cost-conscious care: improving residents' knowledge and attitudes

Teaching of Cost-Effective Care in Orthopaedic Surgery Residency Training: A Survey of Residency Programs in the US

Costs of healthcare in the US continue to rise at rates that are unsustainable. Prior studies, most of which come from non-surgical specialties, indicate that a variety of strategies to teach this material are utilized but without consensus on best practices. No studies exist regarding the teaching of cost-effective care in orthopaedic residency training programs. The goal of this study was to assess the landscape in this area from the perspective of program leadership.

Methods

A survey was developed that was sent to orthopaedic residency program leadership via email through their interaction with the COERG. Additional programs were included to enhance diversity of responding programs. The survey, based on those published from other areas of medicine, included questions about the experiences of the respondents in learning about cost-effective care, as well as how faculty and residents learned about this topic.

Results

Seventy one percent (30) of respondents noted that their faculty did not receive formal training in cost-effective care, and education in this area was likely to come from the department, especially review of practice data (12, 44%). Only 19% (8) of respondents agreed with the statement that "the majority of teaching faculty in our program consistently model cost-effective healthcare to residents". Few of the programs (10, 24%) had formal curricula for residents regarding cost-effective care, and the primary mode of education in cost-effective care was through informal discussions with faculty (17, 43%). Few residents (3, 13%) were able to easily find the costs of tests or procedures.

Discussion

There is not consistent education in cost-effective care for orthopaedic surgery program leadership, faculty, or trainees. The results of this survey demonstrate a need for discussion of best practices, including increasing access to cost data at a local level, and engaging with the AOA, CORD, and the American Academy of Orthopaedic Surgeons more broadly in the development of standard education modules for faculty and residents, to improve the current and future delivery of cost-effective musculoskeletal care.

Cost-Health Literacy as an Educational Objective in Fellowship Training

Physicians are encouraged to communicate with their patients about financial concerns, but are infrequently taught skills necessary to do so. This study describes a curriculum for oncology fellows aimed to improve skills of cost-health literacy, and provides assessment of the curriculum impact on self-perceived cost communication practices. Oncology fellows at a large academic program in 2019 participated in a cost-health literacy curriculum over 3 months. The curriculum consisted of a didactic on financial toxicity (45 min), a problem-based learning case highlighting financial toxicity risk factors and areas for intervention (30 min), and a group discussion (30 min) to review and consolidate strategies to navigate financial toxicity in direct patient care. A cost-health literacy survey was administered at baseline and at the conclusion of the curriculum to evaluate the impact of the program. Of 19 participants, 16 completed both the pre-survey and post-survey and were included in the analysis. After the intervention, participants were more likely to report comfort discussing out-of-pocket costs (50% vs. 19%, p = 0.002) and to feel they could help a patient experiencing financial toxicity (62% vs. 6%, p = 0.005). There was no improvement in the subjective assessment of patient financial distress (57% v 50%, p = 0.759). Oncology fellows can improve self-reported cost-health literacy skills through participation in a targeted, brief curriculum. Further studies are warranted to determine how this approach can be applied in other settings and if it objectively impacts cost communication practices.

Doctors as Resource Stewards? Translating High-Value, Cost-Conscious Care to the Consulting Room

After many policy attempts to tackle the persistent rise in the costs of health care, physicians are increasingly seen as potentially effective resource stewards. Frameworks including the quadruple aim, value-based health care and choosing wisely underline the importance of positive engagement of the health care workforce in reinventing the system-paving the way to real affordability by defining the right care. Current programmes focus on educating future doctors to provide 'high-value, cost-conscious care' (HVCCC), which proponents believe is the future of sustainable medical practice. Such programmes, which aim to extend population-level allocation concerns to interactions between an individual doctor and patient, have generated lively debates about the ethics of expanding doctors' professional accountability. To empirically ground this discussion, we conducted a qualitative interview study to examine what happens when resource stewardship responsibilities are extended to the consulting room. Attempts to deliver HVCCC were found to involve inevitable trade-offs between benefits to the individual patient and (social) costs, medical uncertainty and efficiency, and between resource stewardship and trust. Physicians reconcile this by justifying good-value care in terms of what is in the best interest of individual patients-redefining the currency of value from monetary costs to a patient's quality of life, and cost-conscious care as reflective medical practice. Micro-level resource stewardship thus becomes a matter of working reflexively and reducing wasteful forms of care, rather than of making difficult choices about resource allocation.

Toward High-Value, Cost-Conscious Care - Supporting Future Doctors to Adopt a Role as Stewards of a Sustainable Healthcare System

PHENOMENON

In order to tackle the persistent rise of healthcare costs, physicians as "stewards of scarce resources" could be effective change agents, extending cost containment efforts from national policy to the micro level. Current programs focus on educating future doctors to deliver "high-value, cost-conscious care" (HVCCC). Although the importance of HVCCC education is increasingly recognized, there is a lag in implementation. Whereas recent efforts generated effective interventions that promote HVCCC in a local context, gaps persist in the examination of system factors that underlie broader successful and lasting implementation in educational and healthcare practices.

APPROACH

We conducted a realist evaluation of a program focused on embedding HVCCC in postgraduate education by encouraging and supporting residents to set up "HVCCC projects" to promote HVCCC delivery. We interviewed 39 medical residents and 10 attending physicians involved in such HVCCC projects to examine HVCCC implementation in different educational and healthcare contexts. We held six reflection sessions attended by the program commissioners and educationalists to validate and enrich the findings.

FINDINGS

A realist evaluation was used to unravel the facilitators and barriers that underlie the implementation of HVCCC in a variety of healthcare practices. Whereas research activities regularly stop after the identification of facilitators and barriers, we used these insights to formulate four high-value, cost-conscious care carriers: (1) continue to promote HVCCC awareness, (2) create an institutional structure that fosters HVCCC, (3) continue the focus on projects for embedding HVCCC in practice, (4) generate evidence. The carriers support residents, attendings and others involved in educating physicians in training to develop and implement innovative HVCCC projects.

INSIGHTS

Strategies to promote physician stewardship go beyond the formal curriculum and require a transformation in the informal educational system from one that almost exclusively focuses on medical discussions to one that also considers value and cost as part of medical decision-making. The HVCCC carriers propose a set of strategies and system adaptations that could aid the transformation toward a HVCCC supporting context.

The Effect of Patient and Hospital Characteristics on Total Costs of Peripheral Bypass in New York State

INTRODUCTION

With the aging U.S. population, peripheral vascular procedures will become increasingly common. The objective of this study is to characterize the factors associated with increased total costs after peripheral bypass surgery.

METHODS

Data for 34,819 patients undergoing peripheral bypass surgery in NY State were extracted using the Statewide Planning and Research Cooperative System (SPARCS) database for years 2009-2017. Patient demographics, All Patient Refined Diagnostic Related Groups (APR) severity score, mortality risk, hospital volume, and length of stay data were collected. Primary outcomes were total costs and length of stay. Data were analyzed using univariate and multivariate analysis.

RESULTS

28.1% of peripheral bypass surgeries were performed in New York City. 7.9% of patients had extreme APR severity of illness whereas 32.0% had major APR severity of illness. 6.3% of patients had extreme risk of mortality and 1 in every 5 patients (20%) had major risk of mortality. 24.9% of patients were discharged to a facility. The mean length of stay (LOS) was 9.9 days. Patient LOS of 6-11 days was associated with +$2,791.76 total costs. Mean LOS of ≥ 12 days was associated with + $27,194.88 total costs. Multivariate analysis revealed risk factors associated with an admission listed in the fourth quartile of total costs (≥$36,694.44) for peripheral bypass surgery included NYC location (2.82, CI 2.62-3.04), emergency surgery (1.12, CI 1.03-1.22), extreme APR 2.08, 1.78-2.43, extreme risk of mortality (2.73, 2.34-3.19), emergency room visit (1.68, 1.57-1.81), discharge to a facility (1.27, CI 1.15-1.41), and LOS in the third or fourth quartile (11.09, 9.87-12.46).

CONCLUSION

The cost of peripheral bypass surgery in New York State is influenced by a variety of factors including LOS, patient comorbidity and disease severity, an ER admission, and discharge to a facility.

Preparing Trainees to Deliver High-Value and Cost-Conscious Care in Hematology

PURPOSE OF REVIEW

Despite national-level directives to reduce healthcare waste and promote high-value care (HVC), clinical educators struggle to equip trainees with the knowledge and skills needed to practice value-based care. In this review, we analyze ongoing efforts in graduate medical education (GME) to enhance trainee competence in delivery of high-value and cost-conscious care.

RECENT FINDINGS

Surveys of residents and program directors have shown that while many training programs want to offer formal training in high-value care delivery, few succeed. Although several studies suggest that trainees model stewardship behaviors after clinical preceptors, there remains a shortage of faculty role models skilled in providing HVC. Preparing future hematologist-oncologists to provide cost-conscious care will require significant cultural change at the institutional and program levels and will depend heavily on the development of skilled clinical role models.

Cost-consciousness among Iranian internal medicine residents

Background: Study aimed at assessing residents' cost awareness and their attitude about health care costs.Methods: Internal medicine residents at teaching hospitals of Tehran University of Medical Sciences were surveyed during August-December 2016 using a researcher-made questionnaire comprising attitude statements and cost estimation of diagnostic and treatment items.Results: Eighty-nine residents completed the survey (response rate = 56.6%). The results indicate that less than one quarter (23.69%) of cost estimates were in the range of correct answers. The mean (SD) for correct estimation of medications (out of 8 scores), lab tests (out of 20 scores), and total (out of 35 scores) were 1.25 (0.96), 4.92 (0.27), and 7.97 (0.34), respectively. An analysis of variance showed that the level of residency was positively correlated with residents' correct cost estimation (F (3, 77)=9.98, p = 0.029). There was a significant positive correlation between age of residents with the correct estimate of medication prices (p = 0.018, r = 0.261).Conclusions: The internal medicine residents of Tehran University of Medical Sciences have poor knowledge of health care costs, including medications, diagnostic tests, and hospitalization costs. The results of this study explain the necessity of developing a training program for the transfer of cost information to physicians.

Using Online Simulation of Pediatric Musculoskeletal Cases to Evaluate How Knowledge of Costs Affects Diagnostic Workup

BACKGROUND

Rising healthcare costs have emphasized the need to teach cost-conscious care in graduate medical education.

OBJECTIVE

To teach high-value care and diagnostic evaluation of pediatric musculoskeletal complaints to residents and rotating medical students through online cases.

METHODS

Six online cases were developed and tested at the University Hospitals Cleveland Medical Center. Learners completed modules in one of two groups, those who saw itemized costs of diagnostic tests or those who did not. All learners completed a post-simulation survey. Measured outcomes included presumed diagnosis, cost of evaluation, tests ordered, and perceptions toward high-value care. Simulation outcomes were assessed using paired t-tests. Survey data was analyzed with Chi-squared tests. Outcomes separated by training year were analyzed using ANOVA and post-hoc Tukey test.

RESULTS

Thirty-nine residents and medical students participated and were randomly assigned to complete the cases with costs (n = 19) or no costs (n = 20) displayed during workup. Overall, learners who saw costs spent less money on diagnostics ($1511.11 mean per learner versus $2311.35, p = 0.01). Arrival at the correct diagnosis was associated with lower costs in 3 of 6 cases. When compared to the no cost group, learners in the costs group reported feeling more knowledgeable about the price of diagnostic tests (p = 0.04) and were more likely to factor costs into their practice moving forward (p = 0.03). Third year or above residents demonstrated a statically significant increase in correctly diagnosed cases as opposed to medical students.

CONCLUSIONS

Interventions that challenge learners to integrate costs into decision-making can potentially change future practice.

Translation, transcultural adaptation, and validation of the role-modeling cost-conscious behaviors scale

BACKGROUND

Training in the use of cost-conscious strategies for medical students may prepare new physicians to deliver health care in a more sustainable way. Recently, a role-modeling cost-conscious behaviors scale (RMCCBS) was developed for assessing students' perceptions of their teachers' attitudes to cost consciousness. We aimed to translate the RMCCBS into Brazilian Portuguese, adapt the scale, transculturally, and validate it.

METHODS

We adopted rigorous methodological approaches for translating, transculturally adapting and validating the original scale English version into Brazilian Portuguese. We invited all 400 undergraduate medical students enrolled in the 5th and 6th years of a medical course in Northeast Brazil between January and March 2017 to participate. Of the 400 students, 281 accepted to take part in the study. We analyzed the collected data using the SPSS software version 21 and structural equation modeling (SEM) was performed using AMOS SPSS version 18. We conducted exploratory factor analysis (EFA), varimax rotation, with Kaiser Normalization and Principal Axis Factoring extraction method. We conducted confirmatory factor analysis (CFA), using the SEM. We used the following indexes of adherence of the model: Comparative fit index (CFI), Goodness-of-fit index (GFI) and Tucker-Lewis Index (TLI). We considered the Bayesian Information Criterion (BIC) for Sample-size adjusted. The root mean square error of approximation was calculated. Values below 0.08 were considered acceptable. Composite reliability analyzes were performed to evaluate the accuracy of the instrument. Values above 0.70 were considered satisfactory.

RESULTS

Of the 281 undergraduate medical students, 195 (69.3%) were female. Mean age of participants was 25.0 ± 2.6 years. In the EFA, the KMO was 0.720 and the Bartlett sphericity test was significant (p < 0.001). We conducted the EFA into two factors: role-modeling cost-conscious behaviors in health (seven items) and health waste behaviors (six items). The 13 item-scale was submitted to composite reliability analyzes, obtaining values of 0.813 and 0.761 for the role-modeling cost-conscious behaviors and the health waste behaviors factors, respectively.

CONCLUSIONS

We concluded that the cost-conscious behaviors scale has good psychometric properties and is a valid and reliable instrument for evaluating medical students' perception of their teachers' cost-conscious behaviors.

Knowledge of orthopaedic implant costs and healthcare schemes among orthopaedic residents

There is a paucity of available research on knowledge of orthopaedic implant costs and healthcare schemes among orthopaedic residents. With the rising healthcare costs in Singapore, it is imperative for residents, who are the future surgeons, to understand these issues in order to provide proper counselling and cost-effective management. This study aimed to quantify how accurately they understood these issues and determine if senior residents had better knowledge given their increased experience. An online survey was administered to all orthopaedic residents within a residency programme. There was poor knowledge of implant costs and healthcare schemes among residents. Junior residents fared better at healthcare schemes, while senior residents fared better at estimation of implant costs. Education on these issues should be incorporated into the residency programme to bring about more holistic and cost-conscious clinicians.

High-Value, Cost-Conscious Communication Skills in Undergraduate Medical Education: Validity Evidence for Scores Derived from Two Standardized Patient Scenarios

INTRODUCTION

Training in high-value, cost-conscious care (HVCCC) is increasingly being incorporated into medical school curricula, but students may have limited opportunities to engage patients in HVCCC conversations. The aim of this study was to develop two standardized patient scenarios with associated checklists, hypothesizing that resulting scores would allow for valid formative assessments of HVCCC communication skills.

METHODS

Scenarios were designed to generate a less-is-more conversation (in response to a patient requesting an unnecessary test) and a shared decision-making conversation (in response to a patient choosing between multiple effective treatment options). Checklists were developed by experts and informed by the existing literature. Validity evidence was collected from content, response process, internal structure, relations to other variables, and consequences of testing.

RESULTS

Ninety-three third-year medical students participated during 2014-2015. Mean checklist scores were 79% (SD = 18, Cronbach α = 0.72) and 72% (SD = 13, Cronbach α = 0.62) for the less-is-more and shared decision-making scenarios, respectively. Checklist scores correlated with global ratings of performance (r = 0.65 and 0.54, respectively, both P < 0.001), and overall interrater reliability was good (r = 0.66). Checklist scores discriminated between higher and lower performers (discrimination indices of 0.84 and 0.65, respectively, both P < 0.001). Most students (83/90, 92%) agreed that the session improved their HVCCC communication skills.

CONCLUSIONS

This study provides validity evidence supporting the use of scores derived from two standardized patient scenarios for formative assessment of HVCCC communication skills among third-year medical students. These scenarios can help equip students with practical, patient-centered strategies for promoting value in clinical encounters.

Seeking a stable foundation to build on: 1st-Year residents' views of high-value care teaching

BACKGROUND

United States (US) residency programs have been recently mandated to teach the concept of high-value care (HVC) defined as care that balances the benefits of interventions with their harms and costs. We know that reflective practice is a key to successful learning of HVC; however, little is known about resident perceptions of HVC learning. To better inform HVC teaching in graduate medical education, we asked 1^st-year residents to reflect on their HVC learning.

METHODS

We conducted three focus groups (n = 36) and online forum discussion (n = 13) of 1^st-year internal medicine residents. A constructivist grounded theory approach was used to assess transcripts for recurrent themes to identify the perspectives of residents shared about HVC learning.

RESULTS

Residents perceived their learning of HVC as limited by cultural and systemic barriers that included limited time, fear of missing a diagnosis, perceived expectations of attending physicians, and poor cost transparency. While the residents reported considerable exposure to the construct of HVC, they desired a more consistent framework that could be applied in different situations. In particular, residents reported frustration with variable incentives, objectives, and definitions pertaining to HVC. Suggestions for improvement in HVC teaching outlined three main needs for: (1) a generalizable framework to systematically approach each case that could be later adapted to independent practice; (2) objective real-time data on costs, benefits, and harms of medical interventions; and (3) standardized approach to assess resident competency in HVC.

DISCUSSION

As frontline clinicians and the intended target audience for HVC education, 1^st-year residents are in a unique position to provide feedback to improve HVC teaching in residency. Our findings highlight the learners' desire for a more systematic approach to HVC teaching that includes the development of a stable generalizable framework for decision-making, objective data, and standardized assessment. These findings contrast current educational interventions in HVC that aim at reducing the overuse of specific practices.

[Rationalization of biological tests in cardiology department]

INTRODUCTION

Laboratory tests usually complete clinical examinations for diagnostic, prognostic and even therapeutical care. However, French doctors might too easily prescribe such examinations without knowing their cost. As a matter of fact, the prescription is sometimes excessive or unjustified. Cardiology is not an exception, with costly laboratory tests.

OBJECTIVE

To show that the relevance of each additional test prescription, in a cardiology department, allows a significant reduction of the examination volumes and costs, with no prejudicial effect on patients' care.

METHODS

Two consecutive 2-year periods, between November 1st 2011 and October 31st 2015, - before and after the development of a policy of rationalization of additional tests - were compared. All the patients admitted in our cardiology department during these periods were prospectively included.During 4 years, the volume and the cost of prescription of the most frequent laboratory tests were studied, considering successive half-year periods.

RESULTS

After rationalizing, there was a significant reduction of prescription of the laboratory tests (CBC -72%, BNP -92%, troponin -82%, CRP -89%, liver test -87%, lipid status -80%, TSH -80%, p<0.01).No serious adverse events were reported and no death rate increase was noticed.

CONCLUSION

Rationalizing allows a significant reduction of complementary examinations, with no additional risk for the patient.

Proposed Performance-Based Metrics for the Future Funding of Graduate Medical Education: Starting the Conversation

Graduate medical education (GME) in the United States is financed by contributions from both federal and state entities that total over $15 billion annually. Within institutions, these funds are distributed with limited transparency to achieve ill-defined outcomes. To address this, the Institute of Medicine convened a committee on the governance and financing of GME to recommend finance reform that would promote a physician training system that meets society's current and future needs. The resulting report provided several recommendations regarding the oversight and mechanisms of GME funding, including implementation of performance-based GME payments, but did not provide specific details about the content and development of metrics for these payments. To initiate a national conversation about performance-based GME funding, the authors asked: What should GME be held accountable for in exchange for public funding? In answer to this question, the authors propose 17 potential performance-based metrics for GME funding that could inform future funding decisions. Eight of the metrics are described as exemplars to add context and to help readers obtain a deeper understanding of the inherent complexities of performance-based GME funding. The authors also describe considerations and precautions for metric implementation.

Transitioning to a High-Value Health Care Model: Academic Accountability

Health care spending in the United States has increased to unprecedented levels, and these costs have broken medical providers' promise to do no harm. Medical debt is the leading contributor to U.S. personal bankruptcy, more than 50% of household foreclosures are secondary to medical debt and illness, and patients are choosing to avoid necessary care because of its cost. Evidence that the health care delivery model is contributing to patient hardship is a call to action for the profession to transition to a high-value model, one that delivers the highest health care quality and safety at the lowest personal and financial cost to patients. As such, value improvement work is being done at academic medical centers across the country. To promote measurable improvements in practice on a national scale, academic institutions need to align efforts and create a new model for collaboration, one that transcends cross-institutional competition, specialty divisions, and geographical constraints. Academic institutions are particularly accountable because of the importance of research and education in driving this transition. Investigations that elucidate effective implementation methodologies and evaluate safety outcomes data can facilitate transformation. Engaging trainees in quality improvement initiatives will instill high-value care into their practice. This article charges academic institutions to go beyond dissemination of best practice guidelines and demonstrate accountability for high-value quality improvement implementation. By effectively transitioning to a high-value health care system, medical providers will convincingly demonstrate that patients are their most important priority.

Physician Experiences With High Value Care in Internal Medicine Residency: Mixed-Methods Study of 2003-2013 Residency Graduates

Phenomenon: High healthcare costs and relatively poor health outcomes in the United States have led to calls to improve the teaching of high value care (defined as care that balances potential benefits of interventions with their harms including costs) to physicians-in-training. Numerous interventions to increase high value care in graduate medical education were implemented at the national and local levels over the past decade. However, there has been little evaluation of their impact on physician experiences during training and perceived preparedness for practice. We aimed to assess trends in U.S. physician experiences with high value care during residency over the past decade.

APPROACH

This mixed-methods study used a cross-sectional survey mailed July 2014 to January 2015 to 902 internists who completed residency in 2003-2013, randomly selected from the American Medical Association Masterfile. Quantitative analyses of survey responses and content analysis of free-text comments submitted by respondents were performed.

FINDINGS

A total of 456 physicians (50.6%) responded. Fewer than one fourth reported being exposed to teaching about high value care at least frequently (23.6%, 106/450). Only 43.8% of respondents (193/446) felt prepared to use overtreatment guidelines in conversations with patients, whereas 85.8% (379/447) felt prepared to participate in shared decision making with patients at the conclusion of their training, and 84.4% (380/450) reported practicing generic prescribing. Physicians who completed residency more recently were more likely to report practicing generic prescribing and feeling well prepared to use overtreatment guidelines in conversations with patients (p < .01 for both). Insights: In a national survey, recent U.S. internal medicine residency graduates were more likely to experience high value care during training, which may reflect increased national and local efforts in this area. However, being exposed to high value care as a trainee may not translate into specific tools for practice. In fact, many U.S. internists reported inadequate exposure to prepare them for patient discussions about costs and the use of overtreatment guidelines in practice.

Communicating wisely: teaching residents to communicate effectively with patients and caregivers about unnecessary tests

BACKGROUND

With rising healthcare costs and a focus on quality, there is a growing need to promote resource stewardship in medical education. Physicians need to be able to communicate effectively with patients/caregivers seeking tests and treatments that are unnecessary. This study aimed to evaluate the impact of an interactive workshop on residents' knowledge of resource stewardship and communication skills when counseling patients/caregivers about requests for unnecessary testing.

METHODS

Participants were 83 Internal Medicine and Pediatrics residents at the University of Toronto in 2014-15. The evaluation compared resource stewardship knowledge and communication skills of 57 (69%) residents that attended the resource stewardship workshop to 26 residents (31%) who did not. Knowledge and communication skills assessment consisted of a written test and a structured assessment using standardized patient raters, respectively. A linear regression was applied to determine predictors of overall communication skills performance.

RESULTS

Workshop attendance resulted in better performance on the knowledge test (4.3 ± 1.9 vs. 3.1 ± 1.7 out of 8, p = 0.01), but not better performance on the communication skills assessment (4.1 ± 0.8 vs. 4.0 ± 0.9 out of 5, p = 0.56). Higher training level (p = 0.01) and knowledge test scores (p = 0.046) were independent predictors of better overall communication skills, after adjusting for gender, training level, workshop attendance, knowledge and self-reported prior feedback on communication skills.

CONCLUSIONS

An interactive workshop can improve knowledge of resource stewardship, but improving communication skills with patients/caregivers about unnecessary testing may require additional training or reinforcement in the clinical learning environment. These teaching and assessment approaches can support the integration of education on resource stewardship into medical education.

Science of Health Care Delivery: An Innovation in Undergraduate Medical Education to Meet Society's Needs

The purpose of this special article is to describe a new, 4-year Science of Health Care Delivery curriculum at Mayo Clinic School of Medicine, including curricular content and structure, methods for instruction, partnership with Arizona State University, and implementation challenges. This curriculum is intended to ensure that graduating medical students enter residency prepared to train and eventually practice within person-centered, community- and population-oriented, science-driven, collaborative care teams delivering high-value care. A Science of Health Care Delivery curriculum in undergraduate medical education is necessary to successfully prepare physicians so as to ensure the best clinical outcomes and patient experience of care, at the lowest cost.

Pediatric Training Faculty and Resident Perceptions on Teaching High-Value, Cost-Conscious Care: A Multi-Institutional Study

BACKGROUND AND OBJECTIVES

High-value, cost-conscious care (HVCCC) is care that promotes optimal patient outcomes while reducing unnecessary costs. Teaching to promote HVCCC is essential, yet little research has assessed the dual perspectives of residents and faculty on this topic. Our aim was to investigate pediatric resident and faculty perspectives of HVCCC training and role modeling to more effectively promote curriculum and faculty development on this subject.

METHODS

Pediatric residents and teaching faculty in 2 academic medical centers were surveyed during the 2015-2016 academic year. Questions addressed comfort with HVCCC, current teaching practices, barriers to teaching HVCC, and desired curriculum. Descriptive statistics were used to summarize data, and Fisher's exact or χ² tests were used to assess for associations between responses. Institutional review board approval was obtained at both participating institutions.

RESULTS

We received responses from 51% of faculty (128 of 249) and 60% of residents (73 of 123). Most faculty and residents agreed that HVCCC training is important, but only 26% of residents (18 of 69) felt comfortable practicing HVCCC. Faculty and residents identified lack of training or knowledge (50%, 61 of 121 and 53%, 37 of 70, respectively) and lack of hospital support (73%, 88 of 121 and 69%, 47 of 68, respectively) as the largest barriers. Of residents, >85% (60 of 69) reported a lack of attending physician role modeling. Most faculty (83%, 102 of 123) desired faculty development.

CONCLUSIONS

Residents and faculty agree that HVCCC is important and that training institutions have a responsibility to address it. However, most residents were not comfortable with HVCCC. Faculty development in HVCCC as well as hospital support for access to pricing data will be key for programs to develop effective resident training in this area.

A high value care curriculum for interns: a description of curricular design, implementation and housestaff feedback

PURPOSE

Most residency programmes do not have a formal high value care curriculum. Our goal was to design and implement a multidisciplinary high value care curriculum specifically targeted at interns.

DESIGN

Our curriculum was designed with multidisciplinary input from attendings, fellows and residents at Stanford. Curricular topics were inspired by the American Board of Internal Medicine's Choosing Wisely campaign, Alliance for Academic Internal Medicine, American College of Physicians and Society of Hospital Medicine. Our topics were as follows: introduction to value-based care; telemetry utilisation; lab ordering; optimal approach to thrombophilia work-ups and fresh frozen plasma use; optimal approach to palliative care referrals; antibiotic stewardship; and optimal approach to imaging for low back pain. Our curriculum was implemented at the Stanford Internal Medicine residency programme over the course of two academic years (2014 and 2015), during which 100 interns participated in our high value care curriculum. After each high value care session, interns were offered the opportunity to complete surveys regarding feedback on the curriculum, self-reported improvements in knowledge, skills and attitudinal module objectives, and quiz-based knowledge assessments.

RESULTS

The overall survey response rate was 67.1%. Overall, the material was rated as highly useful on a 5-point Likert scale (mean 4.4, SD 0.6). On average, interns reported a significant improvement in their self-rated knowledge, skills and attitudes after the six seminars (mean improvement 1.6 points, SD 0.4 (95% CI 1.5 to 1.7), p<0.001).

CONCLUSIONS

We successfully implemented a novel high value care curriculum that specifically targets intern physicians.

Reducing Surgical Infections and Implant Costs via a Novel Paradigm of Enhanced Physician Awareness

BACKGROUND

Studies have demonstrated that physicians are often unaware of prescription drug, laboratory, diagnostic, and surgical supply costs.

OBJECTIVE

To investigate the effects of increased physician awareness on infection incidence and surgical device cost containment.

METHODS

Within our institution, physicians were informed of individual, independently adjudicated, craniotomy and ventricular shunt infection incidence and rankings among peers, after which a protocol aimed at reducing skin bacterial burden was implemented for craniotomies. Physicians were also made aware of the costs for shunts and dural substitutes as well as available alternatives.

RESULTS

The combined craniotomy and ventricular shunt infection incidence significantly decreased by 37.5% from 3.2% over May 2011 to April 2015 (132 infections/4137 procedures) to 2.1% over May 2015 to April 2016 (26 infections/1250 procedures; P = .041). The average annual cost savings was $234 175 from preventing postoperative craniotomy infections and $121 125 from preventing postoperative ventricular shunt infections. Total supply costs of ventricular shunts significantly decreased by 26% from $2345 per procedure in fiscal year 2015 to $1747 per procedure in fiscal year 2016 (P &lt; .001). Total supply cost of dural grafts significantly decreased by 54% from $191 per procedure in fiscal year 2015 to $88 per procedure in fiscal year 2016 (P &lt; .001). In total, all initiatives in this study resulted in an estimated annual savings of $567 062.

CONCLUSION

Physician awareness of outcomes and costs resulted in increasing the quality of care, while at the same time reducing the cost.

Predictive Variables for Abnormal Comprehensive Metabolic Panel Testing and Potential Cost Savings in Children Receiving Pediatric Emergency Department Care

OBJECTIVE

The aim of this study was to determine variables predictive of abnormal comprehensive metabolic panel (CMP) results in pediatric emergency department (PED) patients and the potential cost savings of a basic metabolic panel (BMP) versus a CMP.

METHODS

This is a retrospective cross-sectional descriptive study of children (<18 y) at an urban academic PED (annual census, 22,000). Clinical data included 12 clinical variables: right upper quadrant pain, overdose, emesis, liver disorder, malignancy, heart disease, bleeding disorder, jaundice, right upper quadrant tenderness, hepatomegaly, ascites/peripheral edema and shock, and the liver function test (LFT) results not in a BMP (alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, total bilirubin, total protein, and albumin).

RESULTS

There were 207 children in the study population. The mean age was 8 years. There were 106 boys (51%).Variables significantly associated with abnormal LFT result were history of liver disease (P = 0.007), history of heart disease (P = 0.040), jaundice (P = 0.045), and hepatomegaly (P = 0.048). The false-negative rate was 16%. However, of the 10 patients for whom this false-negative rate remained true, the LFT values were marginally abnormal, and performance of further investigation of these results was minimal to none. There were 66 patients with no clinical variables and normal CMP results. With a cost difference of $21 between BMP and CMP, this gives a potential savings of $7125 if extrapolated for 1 year in our PED.

CONCLUSIONS

Limiting testing to a BMP for patients with none of the 12 clinical variables has the potential annual cost savings of $7125.

Role Modeling and Regional Health Care Intensity: U.S. Medical Student Attitudes Toward and Experiences With Cost-Conscious Care

PURPOSE

To examine medical student attitudes toward cost-conscious care and whether regional health care intensity is associated with reported exposure to physician role-modeling behaviors related to cost-conscious care.

METHOD

Students at 10 U.S. medical schools were surveyed in 2015. Thirty-five items assessed attitudes toward, perceived barriers to and consequences of, and observed physician role-modeling behaviors related to cost-conscious care (using scales for cost-conscious and potentially wasteful behaviors; Cronbach alphas of 0.82 and 0.81, respectively). Regional health care intensity was measured using Dartmouth Atlas End-of-Life Chronic Illness Care data: ratio of physician visits per decedent compared with the U.S. average, ratio of specialty to primary care physician visits per decedent, and hospital care intensity index.

RESULTS

Of 5,992 students invited, 3,395 (57%) responded. Ninety percent (2,640/2,932) agreed physicians have a responsibility to contain costs. However, 48% (1,1416/2,960) thought ordering a test is easier than explaining why it is unnecessary, and 58% (1,685/2,928) agreed ordering fewer tests will increase the risk of malpractice litigation. In adjusted linear regression analyses, students in higher-health-care-intensity regions reported observing significantly fewer cost-conscious role-modeling behaviors: For each one-unit increase in the three health care intensity measures, scores on the 21-point cost-conscious role-modeling scale decreased by 4.4 (SE 0.7), 3.2 (0.6), and 3.9 (0.6) points, respectively (all P < .001).

CONCLUSIONS

Medical students endorse barriers to cost-conscious care and encounter conflicting role-modeling behaviors, which are related to regional health care intensity. Enhancing role modeling in the learning environment may help prepare future physicians to address health care costs.

Science of health care delivery as a first step to advance undergraduate medical education: A multi-institutional collaboration

Physicians must possess knowledge and skills to address the gaps facing the US health care system. Educators advocate for reform in undergraduate medical education (UME) to align competencies with the Triple Aim. In 2014, five medical schools and one state university began collaborating on these curricular gaps. The authors report a framework for the Science of Health Care Delivery (SHCD) using six domains and highlight curricular examples from each school. They describe three challenges and strategies for success in implementing SHCD curricula. This collaboration highlights the importance of multi-institutional partnerships to accelerate innovation and adaptation of curricula.

Awareness of Surgeons in Saudi Arabia About the Surgical Costs and Investigations: Multicenter Study

OBJECTIVE

To investigate the level of knowledge and awareness of the cost of the currently used blood investigations, imaging studies, admission cost, and surgical instrument among surgeons in Saudi Arabia.

DESIGN

It was a cross-section study conducted in Riyadh city, the capital of Saudi Arabia.

SETTING

Multihealth centers including main University hospital, Military hospitals, and Ministry of health hospitals. All surgeons in the health facilities were invited to participate in the study. A questionnaire has been formulated, and distributed to all participants. It was composed of 3 sections such as: demographic data, awareness about the cost, and physicians' perception about the cost and the attitude of their institution toward cost practice.

RESULT

Totally, 296 participants were enrolled in the study. More than half of the respondents were females (53.3%). Nearly two-thirds were in the young age group (30-40 years), 41.2% were residents. Only 4.4%, 3.4%, 8.4%, and 3.7% of the surgeons were fully aware of the cost of blood investigations, imaging studies, surgical instruments/prosthesis, and the medication that they prescribe, respectively. Most of them mentioned that their institute neither encourages them to consider a cost-effective practice (86.9%) nor monitor how cost effective is their practice (86.2%).

CONCLUSION

Surgeon's knowledge and awareness about the cost of different medical procedures were insufficient. Surgeons' knowledge and attitudes about costs of care can be improved through the use of audit and feedback with patient cost and charge data, which could be attained through the inclusion of audit and feedback as part of a curriculum teaching.

Exit Survey of Senior Residents: Cost Conscious but Uninformed

Background Cost awareness, to ensure physician stewardship of limited resources, is increasingly recognized as an important skill for physicians. The Accreditation Council for Graduate Medical Education has made cost awareness part of systems-based practice, a core competency of resident education. However, little is known about resident cost awareness. Objective We sought to assess senior resident self-perceived cost awareness and cost knowledge. Methods In March 2014, we conducted a cross-sectional survey of all emergency medicine, internal medicine, obstetrics and gynecology, orthopaedic surgery pediatrics, and medicine-pediatrics residents in their final year at Yale-New Haven Hospital. The survey examined attitudes toward health care costs and residents' estimates of order prices. We considered resident price estimates to be accurate if they were between 50% and 200% of the Connecticut-specific Medicare price. Results We sent the survey to 84 residents and received 47 completed surveys (56% response rate). Although more than 95% (45 of 47) felt that containing costs is the responsibility of every clinician, and 49% (23 of 47) agreed that cost influenced their decision when ordering, only 4% (2 of 47) agreed that they knew the cost of tests being ordered. No residents accurately estimated the price of a complete blood count with differential, and only 2.1% (1 of 47) were accurate for a basic metabolic panel. The overall accuracy of all resident responses was 25%. Conclusions In our study, many trainees exit residency with self-identified deficiencies in knowledge about costs. The findings show the need for educational approaches to improve cost awareness among trainees.

Displaying radiation exposure and cost information at order entry for outpatient diagnostic imaging: a strategy to inform clinician ordering

BACKGROUND

Displaying radiation exposure and cost information at electronic order entry may encourage clinicians to consider the value of diagnostic imaging.

METHODS

An urban safety-net health system displayed radiation exposure information for CT and cost information for CT, MRI and ultrasound on an electronic referral system for outpatient ordering. We assessed whether there were differences in numbers of outpatient CT scans and MRIs per month relative to ultrasounds before and after the intervention, and evaluated primary care clinicians' responses to the intervention.

RESULTS

There were 23 171 outpatient CTs, 15 052 MRIs and 43 266 ultrasounds from 2011 to 2014. The ratio of CTs to ultrasounds decreased by 15% (95% CI 9% to 21%), from 58.2 to 49.6 CTs per 100 ultrasounds; the ratio of MRIs to ultrasounds declined by 13% (95% CI 7% to 19%), from 37.5 to 32.5 per 100. Of 300 invited, 190 (63%) completed the web-based survey in 17 clinics. 154 (81%) noticed the radiation exposure information and 158 (83.2%) noticed the cost information. Clinicians believed radiation exposure information was more influential than cost information: when unsure clinically about ordering a test (radiation=69.7%; cost=46.4%), when a patient wanted a test not clinically indicated (radiation=77.5%; cost=54.8%), when they had a choice between imaging modalities (radiation=77.9%; cost=66.6%), in patient care discussions (radiation=71.9%; cost=43.2%) and in trainee discussions (radiation=56.5%; cost=53.7%). Resident physicians and nurse practitioners were more likely to report that the cost information influenced them (p<0.05).

CONCLUSIONS

Displaying radiation exposure and cost information at order entry may improve clinician awareness about diagnostic imaging safety risks and costs. More clinicians reported the radiation information influenced their clinical practice.

U.S. Internal Medicine Residents' Knowledge and Practice of High-Value Care: A National Survey

PURPOSE

To determine U.S. internal medicine (IM) residents' knowledge of, attitudes toward, and self-reported practice of high-value care (HVC), or care that balances the benefits, harms, and costs of tests and treatments.

METHOD

The authors conducted a cross-sectional survey of U.S. IM residents who took the Internal Medicine In-Training Examination in October 2012. They used multivariable mixed-effects models to examine the relationships between self-reported knowledge and practice of HVC and both exposure to HVC teaching and the care intensity of the training hospital (based on a composite age-sex-race-illness standardized measure of hospital days and inpatient physician visits by Medicare recipients).

RESULTS

Of 21,617 residents who received the survey, 18,102 (83.7%) completed it. Self-reported HVC practices varied: 4,187 of 17,633 respondents (23.7%) agreed that they "share estimated costs of tests and treatments with patients"; 15,549 of 17,626 (88.2%) agreed that they "incorporate patients' values and concerns into clinical decisions." Discussions about balancing the benefits, harms, and costs of treatments with faculty during patient care at least a few times a week were reported by 7,103 of 17,704 respondents (40.1%) and were associated with all self-reported HVC practices. The training hospital's care intensity was inversely associated with self-reported incorporation of costs and patient values into clinical decisions but not with other self-reported behaviors.

CONCLUSIONS

U.S. IM residents reported varying HVC knowledge and practice. Faculty discussions of HVC during patient care correlated with such knowledge and practice and may represent an opportunity to improve residents' competency in providing value-based care.

The Health Innovations Scholars Program: A Model for Accelerating Preclinical Medical Students' Mastery of Skills for Leading Improvement of Clinical Systems

Dramatic changes in health care require physician leadership. Efforts to instill necessary skills often occur late in training. The Heath Innovations Scholars Program (HISP) provided preclinical medical students with experiential learning focused on process improvement. Students led initiatives to improve the discharge process for stroke patients. All students completed an aptitude survey and Quality Improvement Knowledge Assessment Test (QIKAT) before and after the program. Significant improvements occurred across subject areas of leadership (18.4%, P < .001), quality and safety (14.7%, P < .001), and health care systems operations (21.2%, P < .008), and in the domains of knowledge (25.9%, P < .001) and skills (25.2%, P < .001). Average cumulative QIKAT results improved significantly (8.33 to 9.83, P = .04). Three of 4 recommended interventions were implemented. Furthermore, students engaged in other process improvement work on return to their home institutions. The HISP successfully advanced preclinical medical students' ability to lead clinical systems improvement.

A Clinical Process Change and Educational Intervention to Reduce the Use of Unnecessary Preoperative Tests

BACKGROUND

Internal medicine residents receive limited training on how to be good stewards of health care dollars while preserving high-quality care.

INTERVENTION

We implemented a clinical process change and an educational intervention focused on the appropriate use of preoperative diagnostic testing by residents at a Veterans Administration (VA) medical center.

METHODS

The clinical process change consisted of reducing routine ordering of preoperative tests in the absence of specific indications. Residents received a short didactic session, which included algorithms for determining the appropriate use of perioperative diagnostic testing. One outcome was the average cost savings on preoperative testing for a continuous cohort of patients referred for elective knee or hip surgery. Resident knowledge and confidence prior to and after the intervention was measured by pre- and posttest.

RESULTS

The mean cost of preoperative testing decreased from $74 to $28 per patient after the dual intervention (P < .001). The bulk of cost savings came from elimination of unnecessary blood and urine tests, as well as reduced numbers of electrocardiograms and chest radiographs. Among residents who completed the pretest and posttest, the mean score on the pretest was 54%, compared with 80% on the posttest (P  =  .027). Following the educational intervention, 70% of residents stated they felt "very comfortable" ordering appropriate preoperative testing (P  =  .006).

CONCLUSIONS

This initiative required few resources, and it simultaneously improved the educational experience for residents and reduced costs. Other institutions may be able to adopt or adapt this intervention to reduce unnecessary diagnostic expenditures.