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Gujju VR, Khattab M, Kastens V, Saeed G, Chen S, Khattab M. Reducing Unnecessary Complete Blood Count Ordering Through Education and Standardization: A Quality Improvement Initiative. Qual Manag Health Care 2023; 32:197-204. [PMID: 36729860 DOI: 10.1097/qmh.0000000000000387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND OBJECTIVES The American Board of Internal Medicine's Choosing Wisely campaign recommends against ordering repetitive complete blood counts (CBC) in the face of clinical and laboratory stability. METHODS Consecutive patients admitted to a teaching team were included. Intervention 1 was an educational lecture outlining costs of and indications for CBC ordering. Intervention 2 added a simplified algorithm to help providers determine the need for a daily CBC. The primary outcome measure was the number of CBCs ordered per number of patients per day. The secondary outcome measure was net cost saved. The process measures were lecture/poster and algorithm utilization rates. The balancing measure was emergency department visits/readmissions within 7 days of discharge. A statistical process control chart was generated to assess special cause variation. Using R software version 3.5.2, a 2-sample t test and Fisher exact test differences between groups in the outcome and balancing measures. RESULTS One hundred ten patients were included over a 62-day period. The difference between the pre-intervention group and both interventions combined was significant ( P = .000317). Special cause variation was observed after institution of both interventions in conjunction. Net costs saved totaled $43 482. Emergency department visits/readmissions within 7 days were similar between the groups ( P = .1403). CONCLUSIONS Complete blood count ordering patterns and costs were improved through education and providing a decision support tool in the form of a simplified algorithm, without increasing 7-day emergency department visits/readmissions. The algorithm, far less detailed than that previously published, still resulted in significant improvement without unintended consequences, making for a safe and potentially sustainable intervention.
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Affiliation(s)
- Veena R Gujju
- Department of Internal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City (Drs Gujju, Mahmood Khattab, Kastens, and Saeed); Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, College of Public Health, Oklahoma City (Dr Chen); and Department of Internal Medicine, Division of Cardiovascular Diseases, University of Oklahoma Health Sciences Center, Oklahoma City (Dr Mohamad Khattab)
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Yeshoua B, Bowman C, Dullea J, Ditkowsky J, Shyu M, Lam H, Zhao W, Shin JY, Dunn A, Tsega S, S Linker A, Shah M. Interventions to reduce repetitive ordering of low-value inpatient laboratory tests: a systematic review. BMJ Open Qual 2023; 12:bmjoq-2022-002128. [PMID: 36958791 PMCID: PMC10040017 DOI: 10.1136/bmjoq-2022-002128] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 02/05/2023] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND Over-ordering of daily laboratory tests adversely affects patient care through hospital-acquired anaemia, patient discomfort, burden on front-line staff and unnecessary downstream testing. This remains a prevalent issue despite the 2013 Choosing Wisely recommendation to minimise unnecessary daily labs. We conducted a systematic review of the literature to identify interventions targeting unnecessary laboratory testing. METHODS We systematically searched MEDLINE, EMBASE, Cochrane Central and SCOPUS databases to identify interventions focused on reducing daily complete blood count, complete metabolic panel and basic metabolic panel labs. We defined interventions as 'effective' if a statistically significant reduction was attained and 'highly effective' if a reduction of ≥25% was attained. RESULTS The search yielded 5646 studies with 41 articles that met inclusion criteria. We grouped interventions into one or more categories: audit and feedback, cost display, education, electronic medical record (EMR) change, and policy change. Most interventions lasted less than a year and used a multipronged approach. All five strategies were effective in most studies with EMR change being the most commonly used independent strategy. EMR change and policy change were the strategies most frequently reported as effective. EMR change was the strategy most frequently reported as highly effective. CONCLUSION Our analysis identified five categories of interventions targeting daily laboratory testing. All categories were effective in most studies, with EMR change being most frequently highly effective. PROSPERO REGISTRATION NUMBER CRD42021254076.
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Affiliation(s)
- Brandon Yeshoua
- Icahn School of Medicine, Mount Sinai, New York, New York, USA
| | - Chip Bowman
- Department of Medicine, Mount Sinai, New York, New York, USA
| | - Jonathan Dullea
- Icahn School of Medicine, Mount Sinai, New York, New York, USA
| | - Jared Ditkowsky
- Emergency Medicine, Hackensack Meridian Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Margaret Shyu
- Department of Medicine, Mount Sinai, New York, New York, USA
| | - Hansen Lam
- Department of Pathology and Laboratory Medicine, Icahn School of Medicine at Mount Sinai Lillian and Henry M Stratton-Hans Popper, New York, New York, USA
| | - William Zhao
- Icahn School of Medicine, Mount Sinai, New York, New York, USA
| | - Joo Yeon Shin
- Icahn School of Medicine, Mount Sinai, New York, New York, USA
| | - Andrew Dunn
- Hospital Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Surafel Tsega
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Anne S Linker
- Department of Medicine, Mount Sinai, New York, New York, USA
| | - Manan Shah
- Department of Medicine, Mount Sinai, New York, New York, USA
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Forsetlund L, O'Brien MA, Forsén L, Reinar LM, Okwen MP, Horsley T, Rose CJ. Continuing education meetings and workshops: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2021; 9:CD003030. [PMID: 34523128 PMCID: PMC8441047 DOI: 10.1002/14651858.cd003030.pub3] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Educational meetings are used widely by health personnel to provide continuing medical education and to promote implementation of innovations or translate new knowledge to change practice within healthcare systems. Previous reviews have concluded that educational meetings can result in small changes in behaviour, but that effects vary considerably. Investigations into which characteristics of educational meetings might lead to greater impact have yielded varying results, and factors that might explain heterogeneity in effects remain unclear. This is the second update of this Cochrane Review. OBJECTIVES • To assess the effects of educational meetings on professional practice and healthcare outcomes • To investigate factors that might explain the heterogeneity of these effects SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, ERIC, Science Citation Index Expanded (ISI Web of Knowledge), and Social Sciences Citation Index (last search in November 2016). SELECTION CRITERIA We sought randomised trials examining the effects of educational meetings on professional practice and patient outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias. One review author assessed the certainty of evidence (GRADE) and discussed with a second review author. We included studies in the primary analysis that reported baseline data and that we judged to be at low or unclear risk of bias. For each comparison of dichotomous outcomes, we measured treatment effect as risk difference adjusted for baseline compliance. We expressed adjusted risk difference values as percentages, and we noted that values greater than zero favour educational meetings. For continuous outcomes, we measured treatment effect as per cent change relative to the control group mean post test, adjusted for baseline performance; we expressed values as percentages and noted that values greater than zero favour educational meetings. We report means and 95% confidence intervals (CIs) and, when appropriate, medians and interquartile ranges to facilitate comparisons to previous versions of this review. We analysed professional and patient outcomes separately and analysed 22 variables that were hypothesised a priori to explain heterogeneity. We explored heterogeneity by using univariate meta-regression and by inspecting violin plots. MAIN RESULTS We included 215 studies involving more than 28,167 health professionals, including 142 new studies for this update. Educational meetings as the single intervention or the main component of a multi-faceted intervention compared with no intervention • Probably slightly improve compliance with desired practice when compared with no intervention (65 comparisons, 7868 health professionals for dichotomous outcomes (adjusted risk difference 6.79%, 95% CI 6.62% to 6.97%; median 4.00%; interquartile range 0.29% to 13.00%); 28 comparisons, 2577 health professionals for continuous outcomes (adjusted relative percentage change 44.36%, 95% CI 41.98% to 46.75%; median 20.00%; interquartile range 6.00% to 65.00%)) • Probably slightly improve patient outcomes compared with no intervention (15 comparisons, 2530 health professionals for dichotomous outcomes (adjusted risk difference 3.30%, 95% CI 3.10% to 3.51%; median 0.10%; interquartile range 0.00% to 4.00%); 28 comparisons, 2294 health professionals for continuous outcomes (adjusted relative percentage change 8.35%, 95% CI 7.46% to 9.24%; median 2.00%; interquartile range -1.00% to 21.00%)) The certainty of evidence for this comparison is moderate. Educational meetings alone compared with other interventions • May improve compliance with desired practice when compared with other interventions (6 studies, 1402 health professionals for dichotomous outcomes (adjusted risk difference 9.99%, 95% CI 9.47% to 10.52%; median 16.5%; interquartile range 0.80% to 16.50%); 2 studies, 72 health professionals for continuous outcomes (adjusted relative percentage change 12.00%, 95% CI 9.16% to 14.84%; median 12.00%; interquartile range 0.00% to 24.00%)) No studies met the inclusion criteria for patient outcome measurements. The certainty of evidence for this comparison is low. Interactive educational meetings compared with didactic (lecture-based) educational meetings • We are uncertain of effects on compliance with desired practice (3 studies, 370 health professionals for dichotomous outcomes; 1 study, 192 health professionals for continuous outcomes) or on patient outcomes (1 study, 54 health professionals for continuous outcomes), as the certainty of evidence is very low Any other comparison of different formats and durations of educational meetings • We are uncertain of effects on compliance with desired practice (1 study, 19 health professionals for dichotomous outcomes; 1 study, 20 health professionals for continuous outcomes) or on patient outcomes (1 study, 113 health professionals for continuous outcomes), as the certainty of evidence is very low. Factors that might explain heterogeneity of effects Meta-regression suggests that larger estimates of effect are associated with studies judged to be at high risk of bias, with studies that had unit of analysis errors, and with studies in which the unit of analysis was the provider rather than the patient. Improved compliance with desired practice may be associated with: shorter meetings; poor baseline compliance; better attendance; shorter follow-up; professionals provided with additional take-home material; explicit building of educational meetings on theory; targeting of low- versus high-complexity behaviours; targeting of outcomes with high versus low importance; goal of increasing rather than decreasing behaviour; teaching by opinion leaders; and use of didactic versus interactive teaching methods. Pre-specified exploratory analyses of behaviour change techniques suggest that improved compliance with desired practice may be associated with use of a greater number of behaviour change techniques; goal-setting; provision of feedback; provision for social comparison; and provision for social support. Compliance may be decreased by the use of follow-up prompts, skills training, and barrier identification techniques. AUTHORS' CONCLUSIONS Compared with no intervention, educational meetings as the main component of an intervention probably slightly improve professional practice and, to a lesser extent, patient outcomes. Educational meetings may improve compliance with desired practice to a greater extent than other kinds of behaviour change interventions, such as text messages, fees, or office systems. Our findings suggest that multi-strategy approaches might positively influence the effects of educational meetings. Additional trials of educational meetings compared with no intervention are unlikely to change the review findings; therefore we will not further update this review comparison in the future. However, we note that randomised trials comparing different types of education are needed.
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Affiliation(s)
| | - Mary Ann O'Brien
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - Lisa Forsén
- Norwegian Institute of Public Health, Oslo, Norway
| | | | - Mbah P Okwen
- Centre for the Development of Best Practices in Health (CDBPH), Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Tanya Horsley
- Research Unit, Royal College of Physicians and Surgeons of Canada, Ottawa, Canada
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Jain PN, Eagle S, Schechter M, Rhim HJH, Acholonu R. Applying High-Value Care Principles in a Pediatric Case: A Workshop for Health Professions Students. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2020; 16:11030. [PMID: 33241120 PMCID: PMC7678025 DOI: 10.15766/mep_2374-8265.11030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 07/02/2020] [Indexed: 05/25/2023]
Abstract
INTRODUCTION The cost of health care in the US is rapidly rising. Understanding the financial cost of medical care is an important competency for physicians and physicians-in-training. Medical students in their clinical clerkships are being exposed to health care decision-making often for the first time and are forming habits they will carry throughout their training and careers. Teaching high-value care (HVC) principles is crucial for students as they will be the future leaders in health care. METHODS This 1-hour workshop was interactive and aimed to prepare medical students to apply HVC when making medical decisions. The topic of HVC was initially introduced by eliciting tests that students want to order and highlighting the concept of whether or not a test changes the management of the patient. This exercise was followed by a PowerPoint presentation which discussed HVC, Choosing Wisely guidelines in pediatrics, and how to communicate with parents and patients about this topic. RESULTS Of third-year medical students, 125 participated in the workshop, with a survey response rate of 90% (n = 112). Ninety-nine percent reported that this workshop was helpful, and 97% reported that they will change their practice to reflect more cost-conscious care. Most students reported that their knowledge of HVC improved after the session, with 88% reporting scores of 3 (moderately improved) or 4 (significantly improved). DISCUSSION This ready-to-implement workshop offered students an understanding of how the cost of medical care impacts patients and families and how to practice cost-conscious care in pediatrics.
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Affiliation(s)
- Priya N. Jain
- Assistant Professor, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine
| | | | - Miriam Schechter
- Associate Professor, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine
| | - Hai Jung H. Rhim
- Assistant Professor, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine
| | - Rhonda Acholonu
- Assistant Professor, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine
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Edwards AD, Rawji F, Yaskina M, Ross S. Taking the Leap Toward Cost-Conscious Education in Obstetrics and Gynaecology: A Preliminary Randomized Controlled Trial. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 42:1323-1329.e4. [PMID: 32912727 DOI: 10.1016/j.jogc.2020.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 04/19/2020] [Accepted: 04/20/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Residents have a professional obligation with respect to the stewardship of health care resources, yet there is a paucity of research on how to improve residents' cost-awareness. Rising health care expenditures highlight a critical need to improve education related to this competency. This study aimed to test if an educational module can teach residents to make cost-conscious decisions and reduce health care spending. METHODS All Canadian obstetrics and gynaecology residents in 2017 were eligible to participate in this randomized controlled trial. The study was administered online via REDCap. Interested residents were enrolled, stratified by level of training, and block randomized. Residents completed a survey to determine their management of 4 obstetrical scenarios. The intervention group reviewed an educational module on cost-effective ordering prior to completing the survey; the control group was given the option to review the module afterward. The primary outcome was mean total expenditures, compared between the 2 groups using the t test. RESULTS Eighty-five residents were enrolled between August and November 2017, and 63 residents from 13 Canadian residency programs completed the study requirements (33 control and 30 intervention). Mean total expenditure was CAD$291.03 (95% CI 259.38-322.68) versus CAD$192.98 (95% CI 170.67-215.29) for the control and intervention groups, respectively. These figures corresponded to a 33.69% or CAD$98.05 reduction in total expenditures (P = 0.0001). CONCLUSION This educational module decreased expenditures by Canadian obstetrics and gynaecology residents managing hypothetical obstetrical cases. This introduces a potential curriculum innovation to improve resident education in judicious use of health care resources.
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Affiliation(s)
| | - Fahrin Rawji
- Department of Obstetrics and Gynecology, University of Alberta, Edmonton, AB
| | - Maryna Yaskina
- Women and Children's Health Research Institute, University of Alberta, Edmonton, AB
| | - Sue Ross
- Department of Obstetrics and Gynecology, Lois Hole Hospital for Women, University of Alberta, Edmonton, AB
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Nagle SJ, Aakhus E. Preparing Trainees to Deliver High-Value and Cost-Conscious Care in Hematology. Curr Hematol Malig Rep 2020; 15:248-253. [PMID: 32632656 DOI: 10.1007/s11899-020-00595-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- Sarah J Nagle
- Knight Cancer Institute, Oregon Health & Sciences University, Portland, OR, USA
| | - Erin Aakhus
- Department of Medicine, Division of Hematology and Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA. .,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
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Manja V, Monteiro S, You J, Guyatt G, Lakshminrusimha S, Jack SM. Incorporating content related to value and cost-considerations in clinical decision-making: enhancements to medical education. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2019; 24:751-766. [PMID: 31144075 DOI: 10.1007/s10459-019-09896-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 05/07/2019] [Indexed: 06/09/2023]
Abstract
Although incorporating cost-considerations during healthcare decision-making is increasingly important to American patients and physicians, content related to these constructs is not routinely included in medical education. As a result, physicians are ill-equipped to consider costs. This study sought input from practicing physicians on perceived deficiencies in current teaching and recommendations for necessary content to include in medical teaching. We conducted a qualitative descriptive study using semi-structured interviews utilizing a purposeful maximum variation sample of cardiologists and neonatologists practicing in diverse settings. We analyzed interviews using conventional content analysis. 18 cardiologists and 17 neonatologists participated in this study. Respondents perceived that current teaching does not impart sufficient knowledge of value and cost considerations to achieve patient-centered, high-value decision-making. They identified the following priority areas for education related to healthcare costs: the business of medicine and information about out-of-pocket patient costs, training in health research interpretation skills to critically appraise evidence, and communication skills to engage patients as partners in shared decision-making. Participants recommended a variety of teaching methods, including didactic sessions on core topics, role modeling and case studies. American physicians perceive learning needs related to the incorporation of costs into clinical decision-making that can inform curriculum development initiatives in this field. Physicians perceive knowledge of these topics and skills to be crucial to achieving patient-centered high-value care. Concomitant health system reforms supporting the needs of the patient at its center are essential to enable physicians to focus on a patient-centered approach to healthcare delivery.
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Affiliation(s)
- Veena Manja
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
- Department of Surgery, University of California Davis, 2335 Stockton Blvd., Sacramento, CA, 95817, USA.
- Department of Medicine, Department of Veterans Affairs, Northern California Health Care System, Mather, CA, 95655, USA.
| | - Sandra Monteiro
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - John You
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Susan M Jack
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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Stratton TD. Legitimizing Continuous Quality Improvement (CQI): Navigating Rationality in Undergraduate Medical Education. J Gen Intern Med 2019; 34:758-761. [PMID: 30788765 PMCID: PMC6502909 DOI: 10.1007/s11606-019-04875-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
In July of 2015, the Liaison Committee on Medical Education (LCME)-the primary accrediting body for North American allopathic medical schools-formally advanced a model of "formative accreditation" by requiring that medical schools engage in "ongoing planning and continuous quality improvement processes that establish short and long-term programmatic goals, result in the achievement of measurable outcomes that are used to improve programmatic quality, and ensure effective monitoring of the medical education program's compliance with accreditation standards."As these and parallel forces redefine undergraduate medical education (UME) in increasingly rationalistic (i.e., operational, measureable, controllable) terms, efforts to implement meaningful continuous quality improvement (CQI) processes may be challenged to overcome perceptions of questionable purpose, worth, and impact often associated with administration mandates. This commentary discusses potential factors underlying the growing rationalism in UME and offers practical strategies to shield CQI from being passively dismissed, excessively routinized, or redirected toward other institutional ends-remaining, instead, purposefully focused on the task at hand: Enhancing teaching and learning in undergraduate medical curricula.
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Affiliation(s)
- Terry D Stratton
- Office of Medical Education, University of Kentucky College of Medicine, Lexington, KY, USA.
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Impact of the acute care nurse practitioner in reducing the number of unwarranted daily laboratory tests in the intensive care unit. J Am Assoc Nurse Pract 2019; 30:285-292. [PMID: 29757845 DOI: 10.1097/jxx.0000000000000050] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Frequent laboratory testing may be necessary at times for critically ill patients. However, the practice of indiscriminate laboratory test ordering is common. PURPOSE The purpose of this quality improvement project was to assess the effectiveness of the acute care nurse practitioner (ACNP) in reducing the number of unwarranted laboratory tests ordered for ICU patients. To determine whether the presence of an ACNP would make a difference, an ACNP was present on daily ICU multidisciplinary rounds to facilitate the discussion of the laboratory testing needs for each patient for the following 24-hour period. CONCLUSIONS Eighty-one patients were enrolled in the project, 41 in the comparison and 40 in the intervention group. No significant differences were noted between the two groups. The project demonstrated that although there was an increase in tests ordered for the intervention group, the increase was brought about by an increase in specific individual tests rather than an increase in panels of laboratory tests. A reduction in patient cost was observed for the number of tests ordered. No increase in adverse events was noted. IMPLICATIONS FOR PRACTICE Acute care nurse practitioner presence on multidisciplinary rounds may be an effective method to change the practice toward the ordering of tests based on clinical indication.
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Bowman Peterson JM, Duffy B, Duran A, Gladding SP. Interactive value-based curriculum: a pilot study. CLINICAL TEACHER 2018; 16:64-70. [PMID: 29508530 DOI: 10.1111/tct.12771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
| | - Briar Duffy
- Department of Medicine, University of Minnesota Medical School, Minneapolis, USA
| | - Alisa Duran
- Department of Medicine, University of Minnesota Medical School, Minneapolis, USA
| | - Sophia P Gladding
- Department of Medicine, University of Minnesota Medical School, Minneapolis, USA
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Tchou MJ, Walz A, Burgener E, Schroeder A, Blankenburg R. Teaching High-Value Care in Pediatrics: A National Survey of Current Practices and Guide for Future Curriculum Development. Acad Pediatr 2017. [PMID: 29270265 DOI: 10.1016/j.acap.2015.04.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Health care expenditures in the United States are increasing at an unsustainable pace. There have been calls to incorporate education on resource stewardship into medical training, yet the perceived need for and current use of high-value care (HVC) curricula in pediatrics residency programs is unknown. Objective We described the current national landscape of HVC curricula in pediatrics residencies, including characterization of current programs, barriers to the practice of HVC, and clarification of preferred curricula types. Methods Using a cross-sectional study design, we conducted a national, anonymous, web-based survey of pediatrics residency program directors and pediatrics chief residents in fall 2014. Results We received responses from 85 of 199 (43%) pediatrics program directors and 74 of 199 (37%) pediatrics chief residents. Only 10% (8 of 80) of program directors and 12% (8 of 65) of chief residents reported having a formal curriculum on HVC. Respondents identified the largest barriers to HVC as a lack of cost transparency (program directors) and attending physicians having the final say in treatment decisions (chief residents). The majority of respondents (83%, 121 of 146) agreed their program needs a HVC curriculum, and 90% (131 of 145) reported they would use a curriculum if it was available. Respondents significantly preferred a case-based conference discussion format over other approaches. Conclusions Most pediatrics residency programs responding to a survey lacked formal HVC curricula. There is a desire nationally for HVC education in pediatrics, particularly in a case-based discussion format.
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Tchou MJ. Teaching High-Value Care in Pediatrics: A National Survey of Current Practices and Guide for Future Curriculum Development. J Grad Med Educ 2017; 9:741-747. [PMID: 29270265 PMCID: PMC5734330 DOI: 10.4300/jgme-d-17-00139.1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 06/27/2017] [Accepted: 08/07/2017] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Health care expenditures in the United States are increasing at an unsustainable pace. There have been calls to incorporate education on resource stewardship into medical training, yet the perceived need for and current use of high-value care (HVC) curricula in pediatrics residency programs is unknown. OBJECTIVE We described the current national landscape of HVC curricula in pediatrics residencies, including characterization of current programs, barriers to the practice of HVC, and clarification of preferred curricula types. METHODS Using a cross-sectional study design, we conducted a national, anonymous, web-based survey of pediatrics residency program directors and pediatrics chief residents in fall 2014. RESULTS We received responses from 85 of 199 (43%) pediatrics program directors and 74 of 199 (37%) pediatrics chief residents. Only 10% (8 of 80) of program directors and 12% (8 of 65) of chief residents reported having a formal curriculum on HVC. Respondents identified the largest barriers to HVC as a lack of cost transparency (program directors) and attending physicians having the final say in treatment decisions (chief residents). The majority of respondents (83%, 121 of 146) agreed their program needs a HVC curriculum, and 90% (131 of 145) reported they would use a curriculum if it was available. Respondents significantly preferred a case-based conference discussion format over other approaches. CONCLUSIONS Most pediatrics residency programs responding to a survey lacked formal HVC curricula. There is a desire nationally for HVC education in pediatrics, particularly in a case-based discussion format.
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Kynaston JW, Smith T, Batt J. Cost awareness of disposable surgical equipment and strategies for improvement: cross sectional survey and literature review. J Perioper Pract 2017; 27:211-216. [PMID: 29328844 DOI: 10.1177/175045891702701002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 06/01/2017] [Indexed: 06/07/2023]
Abstract
A significant healthcare funding gap has been predicted over the coming years. NHS England has made transparency and cost efficiency a key priority. Healthcare technology accounts for a large portion of healthcare expenditure. The aim of the study was to establish the cost awareness of theatre staff for disposable surgical equipment and to review the current evidence around improving cost awareness. A cross sectional survey was performed. A questionnaire was distributed to consultants, registrars, core surgical trainees and theatre scrub practitioners within an NHS foundation trust and analysed using Microsoft excel 2010. Following the results, which indicated poor cost awareness amongst theatre staff, a literature review was performed to identify strategies to improving cost awareness in healthcare. The results showed that only 22% of all participants (n = 48) were able to estimate cost correctly. There was no significant difference in cost accuracy between surgeons or scrub practitioners. Strategies for improvement in cost awareness were identified. A lack of cost awareness was identified amongst theatre healthcare professionals for common disposable surgical equipment. This is an area which must improve through the use of proven strategies such as national programs, education, visible pricing and price feedback, as highlighted in this paper.
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Summers A, Ruderman C, Leung FH, Slater M. Examining patterns in medication documentation of trade and generic names in an academic family practice training centre. BMC MEDICAL EDUCATION 2017; 17:175. [PMID: 28938883 PMCID: PMC5610475 DOI: 10.1186/s12909-017-1015-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 09/18/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Studies in the United States have shown that physicians commonly use brand names when documenting medications in an outpatient setting. However, the prevalence of prescribing and documenting brand name medication has not been assessed in a clinical teaching environment. The purpose of this study was to describe the use of generic versus brand names for a select number of pharmaceutical products in clinical documentation in a large, urban academic family practice centre. METHODS A retrospective chart review of the electronic medical records of the St. Michael's Hospital Academic Family Health Team (SMHAFHT). Data for twenty commonly prescribed medications were collected from the Cumulative Patient Profile as of August 1, 2014. Each medication name was classified as generic or trade. Associations between documentation patterns and physician characteristics were assessed. RESULTS Among 9763 patients prescribed any of the twenty medications of interest, 45% of patient charts contained trade nomenclature exclusively. 32% of charts contained only generic nomenclature, and 23% contained a mix of generic and trade nomenclature. There was large variation in use of generic nomenclature amongst physicians, ranging from 19% to 93%. CONCLUSIONS Trade names in clinical documentation, which likely reflect prescribing habits, continue to be used abundantly in the academic setting. This may become part of the informal curriculum, potentially facilitating undue bias in trainees. Further study is needed to determine characteristics which influence use of generic or trade nomenclature and the impact of this trend on trainees' clinical knowledge and decision-making.
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Affiliation(s)
- Alexander Summers
- Department of Family and Community Medicine, St. Michael’s Hospital, Toronto, ON Canada
| | - Carly Ruderman
- Department of Family and Community Medicine, St. Michael’s Hospital, Toronto, ON Canada
| | - Fok-Han Leung
- Department of Family and Community Medicine, St. Michael’s Hospital, Toronto, ON Canada
| | - Morgan Slater
- Department of Family and Community Medicine, St. Michael’s Hospital, Toronto, ON Canada
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King BC, DiPace J, Naifeh M, Hammad H, Gerber LM, Abramson E. Pediatric Training Faculty and Resident Perceptions on Teaching High-Value, Cost-Conscious Care: A Multi-Institutional Study. Hosp Pediatr 2017; 7:547-552. [PMID: 28838948 DOI: 10.1542/hpeds.2017-0037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
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.
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Affiliation(s)
- Brian C King
- Departments of Pediatrics, and
- Department of Neonatology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas; and
| | | | - Monique Naifeh
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Hoda Hammad
- Healthcare Policy and Research, New York-Presbyterian Hospital/Weill Cornell Medical College, New York City, New York
| | - Linda M Gerber
- Healthcare Policy and Research, New York-Presbyterian Hospital/Weill Cornell Medical College, New York City, New York
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Agarwal N, Agarwal P, Querry A, Mazurkiewicz A, Whiteside B, Marroquin OC, Koscumb SF, Wecht DA, Friedlander RM. Reducing Surgical Infections and Implant Costs via a Novel Paradigm of Enhanced Physician Awareness. Neurosurgery 2017; 82:661-669. [DOI: 10.1093/neuros/nyx273] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Accepted: 05/16/2017] [Indexed: 11/14/2022] Open
Abstract
Abstract
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 < .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 < .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.
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Affiliation(s)
- Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Prateek Agarwal
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ashley Querry
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Anna Mazurkiewicz
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Brittany Whiteside
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Oscar C Marroquin
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Stephen F Koscumb
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Daniel A Wecht
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert M Friedlander
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Steen AJ, Mann JA, Carlberg VM, Kimball AB, Musty MJ, Simpson EL. Understanding the cost of dermatologic care: A survey study of dermatology providers, residents, and patients. J Am Acad Dermatol 2017; 76:609-617. [PMID: 28189269 DOI: 10.1016/j.jaad.2016.11.049] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 11/15/2016] [Accepted: 11/19/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Aaron J Steen
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire; Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Julianne A Mann
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire; Department of Dermatology, Oregon Health & Science University, Portland, Oregon; Division of Dermatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Valerie M Carlberg
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon; Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Alexa B Kimball
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Michael J Musty
- Department of Mathematics, Dartmouth College, Hanover, New Hampshire
| | - Eric L Simpson
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon.
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Asher E, Mansour J, Wheeler A, Kendrick D, Cunningham M, Parikh S, Zidar D, Harford T, Simon DI, Kashyap VS. Cost awareness decreases total percutaneous coronary intervention procedural cost: The SHOPPING (Show How Options in Price for Procedures Can Be Influenced Greatly) trial. Catheter Cardiovasc Interv 2016; 89:1207-1212. [PMID: 27862875 DOI: 10.1002/ccd.26835] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 09/06/2016] [Accepted: 10/08/2016] [Indexed: 11/11/2022]
Abstract
OBJECTIVES We initiated the SHOPPING Trial (Show How Options in Price for Procedures can be InflueNced Greatly) to see if percutaneous coronary intervention (PCI) procedures can be performed at a lower cost in a single institution. BACKGROUND Procedural practice variability is associated with inefficiency and increased cost. We hypothesized that announcing costs for all supplies during a catheterization procedure and reporting individual operator cost relative to peers would spur cost reduction without affecting clinical outcomes. METHODS Baseline costs of 10 consecutive PCI procedures performed by 9 interventional cardiologists were documented during a 90-day interval. Costs were reassessed after instituting cost announcing and peer reporting the next quarter. The intervention involved labeling of all endovascular supplies, equipment, devices, and disposables in the catheterization laboratory and announcement of the unit price for each piece when requested. For each interventionalist, procedure time and costs were measured and analyzed prior to and after the intervention. RESULTS We found that total PCI procedural cost was significantly reduced by an average of $234.77 (P = 0.01), equating to a total savings of $21,129.30 over the course of 90 PCI procedures. Major Adverse Cardiac and Cerebrovascular Event (MACCE) rates were similar during both periods (2.3% vs. 3.5%, P = NS). CONCLUSIONS Announcing costs in the catheterization laboratory during single vessel PCI and peer reporting leads to cost reduction without affecting clinical outcomes. This intervention may have a role in more complex coronary and peripheral interventional procedures, and in other procedural areas where multiple equipment and device alternatives with variable costs are available. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
| | - John Mansour
- Harrington Heart & Vascular Institute, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Adam Wheeler
- Harrington Heart & Vascular Institute, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Daniel Kendrick
- Harrington Heart & Vascular Institute, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Michael Cunningham
- Harrington Heart & Vascular Institute, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Sahil Parikh
- Harrington Heart & Vascular Institute, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - David Zidar
- Harrington Heart & Vascular Institute, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Todd Harford
- Harrington Heart & Vascular Institute, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Daniel I Simon
- Harrington Heart & Vascular Institute, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Vikram S Kashyap
- Harrington Heart & Vascular Institute, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
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Long T, Bongiovanni T, Dashevsky M, Halim A, Ross JS, Fogerty RL, Silvestri MT. Impact of laboratory cost display on resident attitudes and knowledge about costs. Postgrad Med J 2016; 92:592-6. [DOI: 10.1136/postgradmedj-2015-133851] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 02/25/2016] [Indexed: 11/04/2022]
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Sateia H. Capsule Commentary on Tartaglia et al., Medical Student Perceptions of Cost-Conscious Care in an Internal Medicine Clerkship: A Thematic Analysis. J Gen Intern Med 2015; 30:1535. [PMID: 26001541 PMCID: PMC4579236 DOI: 10.1007/s11606-015-3392-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Heather Sateia
- Johns Hopkins School of Medicine, Lutherville, MD, 21093, USA.
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Johnson DP, Browning WL, Gay JC, Williams DJ. Pediatric hospitalist perceptions regarding trainees' effects on cost and quality of care. Hosp Pediatr 2015; 5:211-8. [PMID: 25832976 DOI: 10.1542/hpeds.2014-0086] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To determine pediatric hospitalists' perceptions about residents' effects on cost and quality of care and their own ability to provide and teach cost-effective, high-quality care. METHODS A 15-item survey assessing hospitalist perceptions of resident impact on costs/quality and their role in teaching cost-effectiveness was developed and sent to 180 hospitalists from 113 institutions in the United States. RESULTS Of 180 hospitalists surveyed, 127 completed surveys (71%). Overall, 76 (60%) and 91 (72%) hospitalists believed that residents increase quality and cost of care, respectively. Respondents who worked with residents all the time were more likely to state that residents increase quality (50 of 70 [71%]) compared with those who worked with residents sometimes (18 of 42 [43%]) or never (8 of 15 [53%]; P=.01). Similarly, academic hospitalists were more likely than community hospitalists to believe that residents increase quality (67 of 103 [65%] vs 9 of 24 [38%]; P=.03). Although only 28 (22%) respondents reported receiving formal cost-effectiveness training, 116 (91%) believed that they provided cost-effective care, and 103 (81%) believed that they were qualified to teach this topic. Most respondents (n=115 [91%]) believed that residents should participate in a cost-effectiveness curriculum. CONCLUSIONS Most respondents felt trainees increase both the costs and quality of care for hospitalized children. The perception of increased quality was associated with increased resident interaction, whereas cost perceptions were similar across groups. Pediatric hospitalists report a lack of formal cost-effectivesness training, but nearly all respondents supported the incorporation of such training into graduate medical education programs.
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Affiliation(s)
| | | | - James C Gay
- General Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt and the Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
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Bowman J, Duran A, Duffy B, Gladding S, Baum K. Teaching high-value care: a novel morning report. CLINICAL TEACHER 2015; 12:165-70. [DOI: 10.1111/tct.12270] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Jill Bowman
- University of Minnesota; Department of Medicine; Minneapolis Minnesota USA
| | - Alisa Duran
- University of Minnesota; Department of Medicine; Minneapolis Minnesota USA
| | - Briar Duffy
- University of Minnesota; Department of Medicine; Minneapolis Minnesota USA
| | - Sophia Gladding
- University of Minnesota; Department of Medicine; Minneapolis Minnesota USA
| | - Karyn Baum
- University of Minnesota; Department of Medicine; Minneapolis Minnesota USA
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Sweigart JR, Tad-Y D, Pierce R, Wagner E, Glasheen JJ. The Health Innovations Scholars Program: A Model for Accelerating Preclinical Medical Students' Mastery of Skills for Leading Improvement of Clinical Systems. Am J Med Qual 2015; 31:293-300. [PMID: 25855673 DOI: 10.1177/1062860615580592] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Richards SE, Shiffermiller JF, Wells AD, May SM, Chakraborty S, Caverzagie KJ, Beachy MW. A Clinical Process Change and Educational Intervention to Reduce the Use of Unnecessary Preoperative Tests. J Grad Med Educ 2014; 6:733-7. [PMID: 26140127 PMCID: PMC4477571 DOI: 10.4300/jgme-d-14-00211.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 07/22/2014] [Accepted: 08/11/2014] [Indexed: 12/19/2022] Open
Abstract
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.
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Ryskina KL, Pesko MF, Gossey JT, Caesar EP, Bishop TF. Brand Name Statin Prescribing in a Resident Ambulatory Practice: Implications for Teaching Cost-Conscious Medicine. J Grad Med Educ 2014; 6:484-8. [PMID: 26279773 PMCID: PMC4535212 DOI: 10.4300/jgme-d-13-00412.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 02/07/2014] [Accepted: 03/17/2014] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Several national initiatives aim to teach high-value care to residents. While there is a growing body of literature on cost impact of physicians' therapeutic decisions, few studies have assessed factors that influence residents' prescribing practices. OBJECTIVE We studied factors associated with intensive health care utilization among internal medicine residents, using brand name statin prescribing as a proxy for higher-cost care. METHODS We conducted a retrospective, cross-sectional analysis of statin prescriptions by residents at an urban academic internal medicine program, using electronic health record data between July 1, 2010, and June 30, 2011. RESULTS For 319 encounters by 90 residents, patients were given a brand name statin in 50% of cases. When categorized into quintiles, the bottom quintile of residents prescribed brand name statins in 2% of encounters, while the top quintile prescribed brand name statins in 98% of encounters. After adjusting for potential confounders, including patient characteristics and supervising attending, being in the primary care track was associated with lower odds (odds ratio [OR], 0.38; P = .02; 95% confidence interval [CI], 0.16-0.86), and graduating from a medical school with an above-average hospital care intensity index was associated with higher odds of prescribing brand name statins (OR, 1.70; P = .049; 95% CI, 1.003-2.88). CONCLUSIONS We found considerable variation in brand name statin prescribing by residents. Medical school attended and residency program type were associated with resident prescribing behavior. Future interventions should raise awareness of these patterns in an effort to teach high-value, cost-conscious care to all residents.
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Horn DM, Koplan KE, Senese MD, Orav EJ, Sequist TD. The impact of cost displays on primary care physician laboratory test ordering. J Gen Intern Med 2014; 29:708-14. [PMID: 24257964 PMCID: PMC4000348 DOI: 10.1007/s11606-013-2672-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 08/12/2013] [Accepted: 10/03/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Physicians are under increased pressure to help control rising health care costs, though they lack information regarding cost implications of patient care decisions. OBJECTIVE To evaluate the impact of real-time display of laboratory costs on primary care physician ordering of common laboratory tests in the outpatient setting. DESIGN Interrupted time series analysis with a parallel control group. PARTICIPANTS Two hundred and fifteen primary care physicians (153 intervention and 62 control) using a common electronic health record between April 2010 and November 2011. The setting was an alliance of five multispecialty group practices in Massachusetts. INTERVENTION The average Medicare reimbursement rate for 27 laboratory tests was displayed within an electronic health record at the time of ordering, including 21 lower cost tests (< $40.00) and six higher cost tests (> $40.00). MAIN MEASURES We compared the change-in-slope of the monthly laboratory ordering rate between intervention and control physicians for 12 months pre-intervention and 6 months post-intervention. We surveyed all intervention and control physicians at 6 months post-intervention to assess attitudes regarding costs and cost displays. KEY RESULTS Among 27 laboratory tests, intervention physicians demonstrated a significant decrease in ordering rates compared to control physicians for five (19%) tests. This included a significant relative decrease in ordering rates for four of 21 (19%) lower cost laboratory tests and one of six (17%) higher cost laboratory tests. A majority (81%) of physicians reported that the intervention improved their knowledge of the relative costs of laboratory tests. CONCLUSIONS Real-time display of cost information in an electronic health record can lead to a modest reduction in ordering of laboratory tests, and is well received. Our study demonstrates that electronic health records can serve as a tool to promote cost transparency and reduce laboratory test use.
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Affiliation(s)
- Daniel M Horn
- Division of General Medicine, Massachusetts General Hospital, Boston, MA, USA
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Teaching high-value, cost-conscious care: improving residents' knowledge and attitudes. Am J Med 2013; 126:838-42. [PMID: 23968904 DOI: 10.1016/j.amjmed.2013.05.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Accepted: 05/29/2013] [Indexed: 11/22/2022]
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Ward RC, Mainiero MB. Graduate Medical Education in the Era of Health Care Reform. J Am Coll Radiol 2013; 10:708-12. [DOI: 10.1016/j.jacr.2013.03.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2013] [Accepted: 03/05/2013] [Indexed: 11/30/2022]
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