A pilot study assessing the influences of charge data and group process on diagnostic test ordering by residents

Randomized Experiments to Reduce Overuse of Health Care: A Scoping Review

OBJECTIVE

Health care overuse is pervasive in countries with advanced health care delivery systems. We hypothesize that effective interventions to reduce low-value care that targets patients or clinicians are mediated by psychological and cognitive processes that change behaviors and that interventions targeting these processes are varied. Thus, we performed a scoping review of experimental studies of interventions, including the interventions' objectives and characteristics, to reduce low-value care that targeted psychological and cognitive processes.

METHODS

We systematically searched databases for experimental studies of interventions to change cognitive orientations and affective states in the setting of health care overuse. Outcomes included observed overuse or a stated intention to use services. We used existing frameworks for behavior change and mechanisms of change to categorize the interventions and the mediating processes.

RESULTS

Twenty-seven articles met the inclusion criteria. Sixteen studied the provision of information to patients or clinicians, with most providing cost information. Six studies used educational interventions, including the provision of feedback about individual practice. Studies rarely used counseling, behavioral nudges, persuasion, and rewards. Mechanisms for behavior change included gain in knowledge or confidence and motivation by social norms.

CONCLUSIONS

In this scoping review, we found few experiments testing interventions that directly target the psychological and cognitive processes of patients or clinicians to reduce low-value care. Most studies provided information to patients or clinicians without measuring or considering mediating factors toward behavior change. These findings highlight the need for process-driven experimental designs, including trials of behavioral nudges and persuasive language involving a trusting patient-clinician relationship, to identify effective interventions to reduce low-value care.

Improving Value-Based Care Education in a Fellowship by Incorporating ACGME Competencies

BACKGROUND

Most value-based care educational interventions teach knowledge of cost but fail to recognize the interrelatedness of the Accreditation Council for Graduate Medical Education (ACGME) competencies of medical knowledge, patient care, practice-based learning and improvement, and systems-based practice.

OBJECTIVE

We analyzed the impact on clinical decision-making of an educational curriculum that incorporated the spectrum of ACGME competencies.

METHODS

Five didactic sessions for a gynecologic oncology fellowship were modified to incorporate cost- and value-based care considerations for each clinical topic addressed. After discussion, the group of fellows identified 1 high-value and 5 low-value practices to target for improvement. The fellows then undertook a chart audit of clinical decisions occurring for patients seen in the outpatient clinics. The frequency of low- and high-value practices was compared before and after the educational intervention.

RESULTS

A total of 126 patients with a cervical cancer diagnosis were seen by participants in the outpatient setting during the entire observation period. After the intervention, the occurrence of 3 identified low-value practices was reduced by 13% to 33%, demonstrating modest effect sizes (effect size ϕ = 0.2-0.3). One high-value practice (smoking cessation counseling) increased 100% after a fellow-initiated quality improvement project was undertaken. Two low-value practices, including routine surveillance imaging, remained unchanged.

CONCLUSIONS

Overlaying value-based concepts in didactic conference teaching resulted in measurable changes in decision-making behavior. Engaging learners in a subsequent, focused quality practice review served as a vital part of their educational experience and allowed us to assess learner competency in its practical application.

Interactive value-based curriculum: a pilot study

BACKGROUND

Current health care costs are unsustainable, with a large percentage of waste attributed to doctor practices. Medical educators are developing curricula to address value-based care (VBC) in education. There is, however, a paucity of curricula and assessments addressing levels higher than 'knows' at the base of Miller's pyramid of assessment. Our objective was to: (1) teach residents the principles of VBC using active learning strategies; and (2) develop and pilot a tool to assess residents' ability to apply principles of VBC at the higher level of 'knows how' on Miller's pyramid.

METHODS

Residents in medicine, medicine-paediatrics and medicine-dermatology participated in a 5-week VBC morning report curriculum using active learning techniques. Early sessions targeted knowledge and later sessions emphasised the application of VBC principles. Medical educators are developing curricula to address value-based care in education RESULTS: Thirty residents attended at least one session and completed both pre- and post-intervention tests, using a newly developed case-based assessment tool featuring a 'waste score' balanced with 'standard of care'. Residents, on average, reduced their waste score from pre-intervention to post-intervention [mean 8.8 (SD 6.3) versus mean 4.7 (SD 4.6), p = 0.001]. For those who reduced their waste score, most maintained or improved their standard of care.

DISCUSSION

Our results suggest that residents may be able to decrease health care waste, with the majority maintaining or improving their management of care in a case-based assessment after participation in the curriculum. We are working to further incorporate VBC principles into more morning reports, and to develop further interventions and assessments to evaluate our residents at higher levels on Miller's pyramid of assessment.

The effect of charge display on cost of care and physician practice behaviors: a systematic review

BACKGROUND

While studies have been published in the last 30 years that examine the effect of charge display during physician decision-making, no analysis or synthesis of these studies has been conducted.

OBJECTIVE

We aimed to determine the type and quality of charge display studies that have been published; to synthesize this information in the form of a literature review.

METHODS

English-language articles published between 1982 and 2013 were identified using MEDLINE, Web of Knowledge, ABI-Inform, and Academic Search Premier. Article titles, abstracts, and text were reviewed for relevancy by two authors. Data were then extracted and subsequently synthesized and analyzed.

RESULTS

Seventeen articles were identified that fell into two topic categories: the effect of charge display on radiology and laboratory test ordering versus on medication choice. Seven articles were randomized controlled trials, eight were pre-intervention vs. post-intervention studies, and two interventions had a concurrent control and intervention groups, but were not randomized. Twelve studies were conducted in a clinical environment, whereas five were survey studies. Of the nine clinically based interventions that examined test ordering, seven had statistically significant reductions in cost and/or the number of tests ordered. Two of the three clinical studies looking at medication expenditures found significant reductions in cost. In the survey studies, physicians consistently chose fewer tests or lower cost options in the theoretical scenarios presented.

CONCLUSIONS

In the majority of studies, charge information changed ordering and prescribing behavior.

Teaching cost-conscious medicine: impact of a simple educational intervention on appropriate abdominal imaging at a community-based teaching hospital

BACKGROUND

Rising costs pose a major threat to US health care. Residency programs are being asked to teach residents how to provide cost-conscious medical care.

METHODS

An educational intervention incorporating the American College of Radiology appropriateness criteria with lectures on cost-consciousness and on the actual hospital charges for abdominal imaging was implemented for residents at Scripps Mercy Hospital in San Diego, CA. We hypothesized that residents would order fewer abdominal imaging examinations for patients with complaints of abdominal pain after the intervention. We analyzed the type and number of abdominal imaging studies completed for patients admitted to the inpatient teaching service with primary abdominal complaints for 18 months before (738 patients) and 12 months following the intervention (632 patients).

RESULTS

There was a significant reduction in mean abdominal computed tomography (CT) scans per patient (1.7-1.4 studies per patient, P < .001) and total abdominal radiology studies per patient (3.1-2.7 studies per patient, P  =  .02) following the intervention. The avoidance of charges solely due to the reduction in abdominal CT scans following the intervention was $129 per patient or $81,528 in total.

CONCLUSIONS

A simple educational intervention appeared to change the radiologic test-ordering behavior of internal medicine residents. Widespread adoption of similar interventions by residency programs could result in significant savings for the health care system.

A review of cost-effectiveness, cost-containment and economics curricula in graduate medical education

OBJECTIVE

Numerous studies performed over the last 30 years suggest that doctors have poor knowledge of the costs of medical care. In most graduate medical education programmes, trainees do not receive formal training in cost-effective medical practice.

METHODS

Comprehensive literature search of electronic bibliographic databases for articles that describe health economics, cost-containment and cost-effectiveness curricula in graduate medical education. Critical appraisal of the literature and qualitative description is presented. Heterogeneity of curricula precluded quantitative summary of data.

RESULTS

We identified 40 articles that met the inclusion criteria for this review. Internal medicine residents were the targeted learners in 27 studies (68%); Family Medicine and Surgery residents were each targeted in five studies (13%); Rehabilitation, Paediatrics and Emergency Medicine residents were each targeted in one study. In general, the methodological quality of the included studies was poor to moderate and mostly targeted knowledge of health economics or cost-containment as opposed to targeting cost-effectiveness. In terms of describing the standard curricular components, studies sufficiently described the different educational strategies (e.g. didactics, interactive, experiential, self-directed) and the component of learner assessment, but lacked the description of other elements such as needs assessment and curriculum evaluation.

CONCLUSION

Cost-effectiveness curricula in graduate medical education are lacking and clearly needed.

What kind of curriculum can better address community needs? Problems arisen by hypothetical-deductive reasoning

The aim of this study was to identify problems arisen by conventional curricula, the guidelines for development of an appropriate educational model for 21st century, and the advantages and disadvantages of the last two curricular models. The medical education literature published from 1995 through 2002 of four reputable journals in medical education were searched (Academic Medicine, Teaching and Learning in Medicine, Medical Education, and Medical Teacher). First the possibly best articles were identified. During the second screening process 76 of 180 articles were found to be highly relevant to our questions. A review of the chosen articles revealed a concept map which starts from currently applied hypothetical-deductive reasoning (HDR)-based curricula in many medical schools all around the world. Results revelaed that continuing cyclical process might be time consuming, enhance burden of faculty and might be stressful for students involved. Current issues in health care system are possibly attributable to current HDR-based curricular models including PBL. Advantages of reiterative PBL theory can not be denied, but it appears that its limited application should be mainly seen in some academic classes to develop some generic transferable skills simultaneously with other teaching methods. Therefore vast application of HDR in clinical settings is not recommended according to our study. However the relationships demonstrated between factors and outcomes mentioned in the concept map can be used to run some new studies to test some hypotheses.

Overuse of prothrombin and partial thromboplastin coagulation tests in medical inpatients

INTRODUCTION

In the monitoring of anticoagulant therapy, prothrombin time (PT) is used to measure the effect of warfarin, whereas the partial thromboplastin time (PTT) measures the therapeutic effect of unfractionated heparin. Low molecular weight heparin (LMWH) does not require routine monitoring.

OBJECTIVE

We collected data on the frequency of simultaneous PT and PTT requests, where only one or neither is indicated, and estimated the potential cost savings if ordering was appropriate.

METHODS

The study was performed at Nassau University Medical Center, a major teaching institution in East Meadow, New York. Inpatient charts were reviewed consecutively until 50 patients prescribed warfarin alone, intravenous heparin alone, or LMWH alone were selected. We then determined which coagulation tests were performed each day for these patients by review of their computerized laboratory results. The costs of laboratory tests were obtained from the hospital laboratory and were used to calculate potential savings.

RESULTS

PT and PTT coagulation tests were requested together in all 50 patients. Seventeen patients on LMWH alone had 30 sets of PT/PTT performed (60 tests). Seventeen patients on intravenous heparin had 87 PTs performed. Twelve patients on warfarin had 60 PTTs performed. In total, 232 unneeded PT or PTTs were ordered in these 50 patients, or 4.6 per patient during hospitalization.

CONCLUSION

The review of the records of 50 medical inpatients found that PT and PTT were invariably requested together, despite a lack of indication. The 50 patients incurred a total of $2434 in unneeded costs. If representative of common clinical practice, significant cost savings may be possible. Education, computerization, and information on costs of individual tests may reduce unneeded investigations.