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Chen KJ, Rascoe A, Su CA, Benedick A, Furdock RJ, Sinkler MA, Vallier HA. Value Challenge: A Bottoms-Up Approach to Minimizing Cost and Waste in Orthopaedic Surgery. JB JS Open Access 2023; 8:JBJSOA-D-22-00129. [PMID: 37063931 PMCID: PMC10090794 DOI: 10.2106/jbjs.oa.22.00129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/18/2023] Open
Abstract
Astronomical increases in medical expenses and waste produce widespread financial and environmental impacts. Minor changes to minimize costs within orthopaedics, the most used surgical subspecialty, could result in substantial savings. However, few orthopaedic surgeons are educated or experienced to implement cost containment strategies. This study aims to investigate cost containment opportunities and provide a framework for educating and incorporating residents into cost-saving initiatives. Methods Orthopaedic surgical residents from an academic program with a Level I trauma center were queried during 2019 to 2022 regarding suggestions for cost containment opportunities. Based on feasibility and the estimated impact, 7 responses were selected to undergo cost-saving analyses. Results The proposed initiatives fell into 2 categories: minimizing waste and optimizing patient care. Eliminating nonessential physical therapy/occupational therapy consults led to the greatest estimated savings ($8.6M charges/year), followed by conserving reusable drill bits ($2.2M/year) and reducing computed tomography scans on lower extremity injuries ($446K/year). Conclusion Current medical training provides limited formal education on cost-effective care. Efforts to mitigate the growing financial and environmental costs of health care should include encouraging and incorporating resident feedback into cost reduction strategies. This tactic will likely have a positive impact on the behavior of such resident surgeons as they enter practice and have more awareness of costs and value. Level of Evidence V (cost-minimization study).
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Affiliation(s)
- Kallie J. Chen
- Department of Orthopaedic Surgery, Case Western Reserve University, Cleveland, Ohio
| | - Alexander Rascoe
- Department of Orthopaedic Surgery, Case Western Reserve University, Cleveland, Ohio
| | - Charles A. Su
- Department of Orthopaedic Surgery, Case Western Reserve University, Cleveland, Ohio
| | - Alex Benedick
- Department of Orthopaedic Surgery, Case Western Reserve University, Cleveland, Ohio
| | - Ryan J. Furdock
- Department of Orthopaedic Surgery, Case Western Reserve University, Cleveland, Ohio
| | - Margaret A. Sinkler
- Department of Orthopaedic Surgery, Case Western Reserve University, Cleveland, Ohio
| | - Heather A. Vallier
- Department of Orthopaedic Surgery, Case Western Reserve University, Cleveland, Ohio
- E-mail address for H.A. Vallier:
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Steijger D, Chatterjee C, Groot W, Pavlova M. Challenges and Limitations in Distributional Cost-Effectiveness Analysis: A Systematic Literature Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:505. [PMID: 36612824 PMCID: PMC9819735 DOI: 10.3390/ijerph20010505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/15/2022] [Accepted: 12/23/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Cost-effectiveness is a tool to maximize health benefits and to improve efficiency in healthcare. However, efficient outcomes are not always the most equitable ones. Distributional cost-effectiveness analysis (DCEA) offers a framework for incorporating equity concerns into cost-effectiveness analysis. OBJECTIVE This systematic review aims to outline the challenges and limitations in applying DCEA in healthcare settings. METHODS We searched Medline, Scopus, BASE, APA Psych, and JSTOR databases. We also included Google Scholar. We searched for English-language peer-reviewed academic publications, while books, editorials and commentary papers were excluded. Titles and abstract screening, full-text screening, reference list reviews, and data extraction were performed by the main researcher. Another researcher checked every paper for eligibility. Details, such as study population, disease area, intervention and comparators, costs and health effects, cost-effectiveness findings, equity analysis and effects, and modelling technique, were extracted. Thematic analysis was applied, focusing on challenges, obstacles, and gaps in DCEA. RESULTS In total, 615 references were identified, of which 18 studies met the inclusion criteria. Most of these studies were published after 2017. DCEA studies were mainly conducted in Europe and Africa and used quality health-adjusted measurements. In the included studies, absolute inequality indices were used more frequently than relative inequality indices. Every stage of the DCEA presented challenges and/or limitations. CONCLUSION This review provides an overview of the literature on the DCEA in healthcare as well as the challenges and limitations related to the different steps needed to conduct the analysis. In particular, we found problems with data availability, the relative unfamiliarity of this analysis among policymakers, and challenges in estimating differences among socioeconomic groups.
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Affiliation(s)
- Dirk Steijger
- Master’s Program Global Health, Faculty of Health, Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Chandrima Chatterjee
- Master’s Program Global Health, Faculty of Health, Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Wim Groot
- Department of Health Services Research, CAPHRI, Maastricht University Medical Centre, Faculty of Health, Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Milena Pavlova
- Department of Health Services Research, CAPHRI, Maastricht University Medical Centre, Faculty of Health, Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
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Turner A, Ryan M, Wolvaardt J. We know but we hope: A qualitative study of the opinions and experiences on the inclusion of management, health economics and research in the medical curriculum. PLoS One 2022; 17:e0276512. [PMID: 36269759 PMCID: PMC9586360 DOI: 10.1371/journal.pone.0276512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 10/10/2022] [Indexed: 11/25/2022] Open
Abstract
The achievement of global and national health goals requires a health workforce that is sufficient and trained. Despite considerable steps in medical education, the teaching of management, health economics and research skills for medical doctors are often neglected in medical curricula. This study explored the opinions and experiences of medical doctors and academic educationalists on the inclusion of management, health economics and research in the medical curriculum. A qualitative study was undertaken at four medical schools in Southern Africa (February to April 2021). The study population was medical doctors and academic educationalists. Semi-structured interviews with purposively sampled participants were conducted. All interviews were recorded and professionally transcribed. Constructivist grounded theory guided the analysis with the use of ATLAS.ti version 9.1.7.0 software. In total, 21 academic educationalists and 28 medical doctors were interviewed. In the first theme We know, participants acknowledged the constraints of medical schools but were adamant that management needed to be taught intentionally and explicitly. The teaching and assessment of management and health economics was generally reported to be ad hoc and unstructured. There was a desire that graduates are able to use, but not necessarily do research. In comparison to management and research, support for the inclusion of health economics in the curriculum was insignificant. Under We hope, educationalists hoped that the formal clinical teaching will somehow instil values and best practices of management and that medical doctors would become health advocates. Most participants wished that research training could be optimised, especially in relation to the duration of allocated time; the timing in the curriculum and the learning outcomes. Despite acknowledgement that management and research are topics that need to be taught, educationalists appeared to rely on chance to teach and assess management in particular. These qualitative study findings will be used to develop a discrete choice experiment to inform optimal curricula design.
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Affiliation(s)
- Astrid Turner
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
- * E-mail:
| | - Mandy Ryan
- Health Economics Research Unit, University of Aberdeen, King’s College, Aberdeen, Scotland
| | - Jacqueline Wolvaardt
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
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Kennedy C, Smith A, O’Brien E, Rice J, Barry M. Prescribers’ knowledge of drug costs: a contemporary Irish study. DRUGS & THERAPY PERSPECTIVES 2021. [DOI: 10.1007/s40267-021-00830-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Nahmias J, Smith B, Grigorian A, Watson S, Saba T, Duong W, McRae D, Nguyen N, Dolich M. Implementation of a High-Value Care Curriculum for General Surgery Residents. JOURNAL OF SURGICAL EDUCATION 2020; 77:1194-1201. [PMID: 32245718 DOI: 10.1016/j.jsurg.2020.03.006] [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: 01/30/2020] [Revised: 03/05/2020] [Accepted: 03/06/2020] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Healthcare expenditures account for more than 3.5 trillion dollars annually with estimates of nearly one-half being wasteful. High-value care (HVC) balances the benefits, harms, and costs of healthcare. Since 2012, the American College of Physicians and Accreditation Council for Graduate Medical Education developed a HVC curriculum and incorporated HVC into milestones for medicine residents. However, currently no HVC curriculum or milestones exist for general surgery residents (GSR). We sought to implement a HVC curriculum for GSR and evaluate awareness and attitudes toward HVC, hypothesizing improved resident awareness and attitudes toward HVC without affecting patient outcomes. METHODS A prospective comparison between pre-HVC curriculum (7/1/2017-11/30/2017) and post-HVC curriculum (2/1/2018-6/30/2018) was performed. The curriculum included 6 didactic lectures with group discussions. A 14-question Likert-scale survey evaluating awareness, use of, and attitudes toward HVC was performed on all GSR. Additional patient outcomes were collected for all trauma patients cared for during the study period. Bivariate analysis using Mann-Whitney U test was performed. RESULTS There were 38/38 GSR respondents (100% response rate) for the pre-HVC survey and 35/38 (92.1% response rate) for the post-HVC survey. More post-HVC respondents somewhat agreed (34.3% vs 5.3%) and less strongly disagreed (31.4% vs 52.6%) with improved knowledge of where to find costs of labs/imaging/treatment (p = 0.02) compared to the pre-HVC group. More post-HVC respondents strongly agreed they balanced the benefit of clinical care with costs and harm when treating patients (25.7% vs 21.1%; p = 0.01). More post-HVC respondents strongly agreed they customized care plans to incorporate patients' values/concerns after implementation of the curriculum (51.4% vs 23.7%, p = 0.0006). From 3254 trauma patients studied, 1722 (52.9%) were pre-HVC and 1532 (47.1%) post-HVC patients. There was no difference between the pre- and post-HVC-curriculum trauma patients in terms of demographics and outcomes such as mortality (3.6% vs 2.4%, p = 0.07) and median length of stay (2 vs 2 days, p = 0.6). CONCLUSIONS Implementation of a HVC curriculum for GSR led to improved awareness regarding healthcare costs and customizing decision plans for patients, with no difference in trauma patient outcomes. Future research incorporating cost data is needed; however, with implementation of the 2020 general surgery milestones (addition of Systems-Based Practice-3), this curriculum could prove beneficial.
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Affiliation(s)
- Jeffry Nahmias
- Department of Surgery, University of California, Irvine, Orange, California
| | - Brian Smith
- Department of Surgery, University of California, Irvine, Orange, California
| | - Areg Grigorian
- Department of Surgery, University of California, Irvine, Orange, California
| | - Stephanie Watson
- Department of Surgery, University of California, Irvine, Orange, California
| | - Tania Saba
- Department of Surgery, University of California, Irvine, Orange, California
| | - William Duong
- Department of Surgery, University of California, Irvine, Orange, California.
| | - Deena McRae
- Department of Surgery, University of California, Irvine, Orange, California
| | - Ninh Nguyen
- Department of Surgery, University of California, Irvine, Orange, California
| | - Matthew Dolich
- Department of Surgery, University of California, Irvine, Orange, California
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Ginzburg SB, Schwartz J, Deutsch S, Elkowitz DE, Lucito R, Hirsch JE. Using a Problem/Case-Based Learning Program to Increase First and Second Year Medical Students' Discussions of Health Care Cost Topics. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2019; 6:2382120519891178. [PMID: 31840079 PMCID: PMC6902390 DOI: 10.1177/2382120519891178] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 11/06/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND The rising costs of health care in the United States are unsustainable and gaps in physician knowledge of how to provide care at a lower cost remains a contributing factor. It has been suggested that learning about health care costs should be incorporated into existing, already overburdened medical school curricula. OBJECTIVE To increase the discussion of health care costs among first and second year medical students, we added a component of health care cost education to an existing problem/case-based learning (PBL/CBL) program without adding curricular time. DESIGN A total of 98 medical students participated in this study throughout the first 2 years of their educational program. Students were charged with researching and discussing health care cost topics as part of their weekly PBL/CBL case conferences. Faculty facilitators tracked each student's participation in discussions of health care cost topics as well as how often students initiated new conversations about health care cost topics during their case conferences. RESULTS 100% of students engaged in conversations about health care cost topics throughout their first and second year PBL/CBL program. In addition, students increasingly initiated new conversations about health care cost topics as they progressed through their courses from the first to the second year (R 2 = 0.887, P < .01). CONCLUSIONS Sensitizing medical students early during their educational program to incorporate health care cost topics into their PBL/CBL case conferences proved an effective means for having them engage in conversations related to health care costs. These results offer a new, time-efficient option for incorporating health care cost topics for schools with PBL/CBL programs.
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Affiliation(s)
- Samara B Ginzburg
- Department of Science Education, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hofstra University, Hempstead, NY, USA
| | - Jessica Schwartz
- Department of Science Education, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hofstra University, Hempstead, NY, USA
| | - Susan Deutsch
- Department of Science Education, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hofstra University, Hempstead, NY, USA
| | - David E Elkowitz
- Department of Science Education, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hofstra University, Hempstead, NY, USA
| | - Robert Lucito
- Department of Science Education, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hofstra University, Hempstead, NY, USA
| | - Jerrold E Hirsch
- Department of Population Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hofstra University, Hempstead, NY, USA
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Dewan M, Herrmann LE, Tchou MJ, Parsons A, Muthu N, Tenney-Soeiro R, Fieldston E, Lindell RB, Dziorny A, Gosdin C, Bamat TW. Development and Evaluation of High-Value Pediatrics: A High-Value Care Pediatric Resident Curriculum. Hosp Pediatr 2018; 8:785-792. [PMID: 30425056 DOI: 10.1542/hpeds.2018-0115] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Low-value health care is pervasive in the United States, and clinicians need to be trained to be stewards of health care resources. Despite a mandate by the Accreditation Council for Graduate Medical Education to educate trainee physicians on cost awareness, only 10% of pediatric residency programs have a high-value care (HVC) curriculum. To meet this need, we set out to develop and evaluate the impact of High-Value Pediatrics, an open-access HVC curriculum. High-Value Pediatrics is a 3-part curriculum that includes 4 standardized didactics, monthly interactive morning reports, and an embedded HVC improvement project. Curriculum evaluation through an anonymous, voluntary survey revealed an improvement in the self-reported knowledge of health care costs, charges, reimbursement, and value (P < .05). Qualitative results revealed self-reported behavior changes, and HVC improvement projects resulted in higher-value patient care. The implementation of High-Value Pediatrics is feasible and reveals improved knowledge and attitudes about HVC. HVC improvement projects augmented curricular knowledge gains and revealed behavior changes. It is imperative that formal high-value education be taught to every pediatric trainee to lead the culture change that is necessary to turn the tide against low-value health care. In addition, simultaneous work on faculty education and attention to the hidden curriculum of low-value care is needed for sustained and long-term improvements.
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Affiliation(s)
- Maya Dewan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; .,Critical Care Medicine, and.,James M. Anderson Center for Health Systems Excellence and
| | - Lisa E Herrmann
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and
| | - Michael J Tchou
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.,James M. Anderson Center for Health Systems Excellence and.,Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and
| | | | - Naveen Muthu
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rebecca Tenney-Soeiro
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Evan Fieldston
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Robert B Lindell
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine and
| | - Adam Dziorny
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine and
| | - Craig Gosdin
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and
| | - Tara W Bamat
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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8
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Tomaselli PJ, Papanagnou D, Karademos JE, Teixeira E, Zhang XC. Gamification of Hospital Utilization: Incorporating Cost-consciousness in Daily Practices. Cureus 2018; 10:e3094. [PMID: 30324047 PMCID: PMC6171783 DOI: 10.7759/cureus.3094] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Healthcare costs in the United States have skyrocketed over the past decade, contributing to an estimated $750 billion in wasteful spending annually. Despite the demand to improve residency education on value-based, cost-conscious healthcare, there is no consensus on how to best teach this practice. Traditional lectures have failed to demonstrate enduring change in clinical practice patterns, provider attitudes, and reductions in hospital expenditures. We sought to evaluate whether gamification is an effective pedagogical tool to teach cost-consciousness to emergency medicine (EM) residents by creating a 60-minute interactive session based on the popular gameshow, the Price is Right. Costs and associated charges for common laboratory tests, radiographic studies, medications, and common physical resources typically found in the emergency department (ED) were first obtained through direct communication with the ED clinical director and hospital leadership. The session itself consisted of three phases with several Price-is-Right-themed games, which included realistic visual stimuli reminiscent of the gameshow that were created by the authors using the PowerPoint. Formal quantitative and qualitative feedback was solicited at the end of the session. Quantitative evaluation of the educational intervention was obtained through a 22-item questionnaire using a five-point Likert-type scale from 19 of the 22 enrolled residents (86% response rate). Responses were generally very positive with an overall course rating score of 4.16 (SD +/- 0.90). Qualitative feedback identified learners’ predilection for gamified delivery of nonclinical content during conference. The majority of residents (89%) recommend the activity to be used in subsequent offerings to other learners. With healthcare costs on the rise, our feasibility study demonstrated that gamification is an effective way to teach mindful, cost-conscious care to EM residents. Gamification offers a fun and engaging alternative that should be further utilized in EM educational formats. Future studies are needed to longitudinally assess the learner retention and cost-containment practices.
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Affiliation(s)
- Peter J Tomaselli
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, USA
| | - Dimitrios Papanagnou
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, USA
| | - Jonathan E Karademos
- Department of Emergency Medicine, Thomas Jefferson University Hospitals, Philadelphia, USA
| | - Elizabeth Teixeira
- Department of Emergency Medicine, Thomas Jefferson University Hospitals, Philadelphia, USA
| | - Xiao Chi Zhang
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, USA
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Zhou LL, Tait G, Sandhu S, Steiman A, Lake S. Online virtual cases to teach resource stewardship. CLINICAL TEACHER 2018; 16:220-225. [PMID: 29893013 DOI: 10.1111/tct.12804] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Linghong Linda Zhou
- Department of Dermatology and Skin ScienceUniversity of British Columbia Vancouver Canada
| | - Gordon Tait
- Department of AnaesthesiaUniversity Health NetworkUniversity of Toronto Toronto Ontario Canada
| | - Sharron Sandhu
- Department of RheumatologySunnybrook Health Sciences CentreUniversity of Toronto Toronto Ontario Canada
| | - Amanda Steiman
- Department of RheumatologyMount Sinai HospitalUniversity of Toronto Toronto Ontario Canada
| | - Shirley Lake
- Department of RheumatologySunnybrook Health Sciences CentreUniversity of Toronto Toronto Ontario Canada
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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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12
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Van der Wees PJ, Wammes JJG, Jeurissen PPT, Westert GP. Stewardship of primary care physicians to contain cost in health care: an international cross-sectional survey. Fam Pract 2017; 34:717-722. [PMID: 28968666 DOI: 10.1093/fampra/cmx077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE Physician stewardship towards cost control is potentially important in enhancing the financial sustainability of health care systems. OBJECTIVE Aim of this study was to identify the level of stewardship of cost containment of primary care physicians (PCPs) and to assess the associations between stewardship and characteristics of PCPs and health care systems. METHODS Secondary analysis of data from a cross-sectional survey among 10 countries: Australia, Canada, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland, UK and USA. Participants were a random sample of 33312 PCPs with 11547 responses (34.7%). Outcome measure was a stewardship scale addressing cost-awareness and cost-consideration. RESULTS Across countries, 41.6% and 45.7% of the PCPs responded that they often were aware of treatment costs and considered cost, respectively. Female PCPs were less aware of costs (OR: 0.75; 95% CI: 0.69-0.81) and considered costs less frequently in making treatment decisions (OR: 0.82; 95% CI: 0.76-0.89). Older PCPs were more aware of the costs than younger PCPs for all age categories compared to those <35 years (P < 0.001). PCPs older than 65 years (OR: 0.64; 95% CI: 0.54-0.78) and 55-64 years (OR: 0.84; 95%CI: 0.73-0.97) were less likely to consider costs than the youngest age group. Cost-consideration of PCPs residing in countries with a single payer system was lower (OR: 0.58; 95% CI 0.35-0.95) than their colleagues in multiple payer systems. CONCLUSION PCPs show moderate stewardship of health care resources with large intercountry differences. Cost-awareness may not be a necessary precondition for cost-consideration, and policies aimed at raising cost-consideration may be more important.
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Affiliation(s)
- Philip J Van der Wees
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare (IQ Healthcare), Celsus Academy for Sustainable Healthcare, Nijmegen, The Netherlands
| | - Joost J G Wammes
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare (IQ Healthcare), Celsus Academy for Sustainable Healthcare, Nijmegen, The Netherlands
| | - Patrick P T Jeurissen
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare (IQ Healthcare), Celsus Academy for Sustainable Healthcare, Nijmegen, The Netherlands
| | - Gert P Westert
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare (IQ Healthcare), Celsus Academy for Sustainable Healthcare, Nijmegen, The Netherlands
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Moser EM, Fazio SB, Packer CD, Glod SA, Smith CD, Alguire PC, Huang GC. SOAP to SOAP-V: A New Paradigm for Teaching Students High Value Care. Am J Med 2017; 130:1331-1336.e2. [PMID: 28778492 DOI: 10.1016/j.amjmed.2017.07.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 07/28/2017] [Indexed: 10/19/2022]
Affiliation(s)
| | | | | | | | - Cynthia D Smith
- American College of Physicians, Philadelphia, Pa; University of Pennsylvania, Philadelphia
| | - Patrick C Alguire
- American College of Physicians, Philadelphia, Pa; Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pa
| | - Grace C Huang
- Harvard Medical School, Boston, Mass; Carl J. Shapiro Institute for Education and Research at Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
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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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Tawfik B, Collins JB, Fino NF, Miller DP. House Officer-Driven Reduction in Laboratory Utilization. South Med J 2016; 109:5-10. [PMID: 26741863 DOI: 10.14423/smj.0000000000000390] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To determine whether sharing laboratory charge and personal utilization information with physicians can reduce laboratory test orders and expenditures, thereby decreasing the overutilization of laboratory testing. METHODS This was a prospective study. By querying our electronic medical records, we calculated the median laboratory charges per patient/per day (PP/PD) and median laboratory tests ordered PP/PD for the resident general internal medicine and hospitalist services. For 10 weeks, we shared this team-based information with physicians with weekly updates. We calculated total laboratory charges for the 10 most common discharge diagnoses to capture laboratory charges for entire episodes of care. RESULTS During the intervention, the mean number of laboratory tests ordered PP/PD by resident service decreased from 5.56 to 5.17 (-0.389, P <0.001); the mean charge PP/PD decreased from $488 to $461 (-$27, P < 0.001). The hospitalist service decreased the number of laboratory tests ordered PP/PD from 3.54 to 3.36 (-0.18, P = 0.77) and the mean charge PP/PD decreased from $331 to $301 (-$30, P = 0.96). The statistically significant decline in laboratory charges persisted after controlling for the 10 most common discharge diagnoses. Compared with the 3-month period before the study began, physicians in the 10-week intervention period ordered 1464 fewer laboratory tests, resulting in a $188,000 reduction in charges and a 3% to 4% reduction in utilization. CONCLUSIONS Informing physicians of the charges for laboratory tests and their personal utilization patterns can reduce the number of laboratory tests ordered and laboratory expenditures, especially for physicians in training.
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Affiliation(s)
- Bernard Tawfik
- From the Department of Internal Medicine, Wake Forest School of Medicine, the Department of Biostatistical Sciences, Wake Forest Baptist Health Performance Improvement, and the Department of Biostatistics and Bioinformatics, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - J B Collins
- From the Department of Internal Medicine, Wake Forest School of Medicine, the Department of Biostatistical Sciences, Wake Forest Baptist Health Performance Improvement, and the Department of Biostatistics and Bioinformatics, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Nora F Fino
- From the Department of Internal Medicine, Wake Forest School of Medicine, the Department of Biostatistical Sciences, Wake Forest Baptist Health Performance Improvement, and the Department of Biostatistics and Bioinformatics, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - David P Miller
- From the Department of Internal Medicine, Wake Forest School of Medicine, the Department of Biostatistical Sciences, Wake Forest Baptist Health Performance Improvement, and the Department of Biostatistics and Bioinformatics, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Sanclemente-Ansó C, Bosch X, Salazar A, Moreno R, Capdevila C, Rosón B, Corbella X. Cost-minimization analysis favors outpatient quick diagnosis unit over hospitalization for the diagnosis of potentially serious diseases. Eur J Intern Med 2016; 30:11-17. [PMID: 26944565 DOI: 10.1016/j.ejim.2015.12.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 12/17/2015] [Accepted: 12/18/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Quick diagnosis units (QDUs) are a promising alternative to conventional hospitalization for the diagnosis of suspected serious diseases, most commonly cancer and severe anemia. Although QDUs are as effective as hospitalization in reaching a timely diagnosis, a full economic evaluation comparing both approaches has not been reported. AIMS To evaluate the costs of QDU vs. conventional hospitalization for the diagnosis of cancer and anemia using a cost-minimization analysis on the proven assumption that health outcomes of both approaches were equivalent. METHODS Patients referred to the QDU of Bellvitge University Hospital of Barcelona over 51 months with a final diagnosis of severe anemia (unrelated to malignancy), lymphoma, and lung cancer were compared with patients hospitalized for workup with the same diagnoses. The total cost per patient until diagnosis was analyzed. Direct and non-direct costs of QDU and hospitalization were compared. RESULTS Time to diagnosis in QDU patients (n=195) and length-of-stay in hospitalized patients (n=237) were equivalent. There were considerable costs savings from hospitalization. Highest savings for the three groups were related to fixed direct costs of hospital stays (66% of total savings). Savings related to fixed non-direct costs of structural and general functioning were 33% of total savings. Savings related to variable direct costs of investigations were 1% of total savings. Overall savings from hospitalization of all patients were €867,719.31. CONCLUSION QDUs appear to be a cost-effective resource for avoiding unnecessary hospitalization in patients with anemia and cancer. Internists, hospital executives, and healthcare authorities should consider establishing this model elsewhere.
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Affiliation(s)
- Carmen Sanclemente-Ansó
- Department of Internal Medicine, Bellvitge University Hospital, University of Barcelona, Bellvitge Biomedical Research Institute, L'Hospitalet de Llobregat, Barcelona, Catalonia, Spain.
| | - Xavier Bosch
- Department of Internal Medicine, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomèdiques Auguts Pi i Sunyer, Barcelona, Catalonia, Spain
| | - Albert Salazar
- Emergency Department, Bellvitge University Hospital, Department of Medicine, University of Barcelona, Bellvitge Biomedical Research Institute, L'Hospitalet de Llobregat, Barcelona, Catalonia, Spain
| | - Ramón Moreno
- Department of Economic Development, Bellvitge University Hospital, University of Barcelona, Bellvitge Biomedical Research Institute, L'Hospitalet de Llobregat, Barcelona, Catalonia, Spain
| | - Cristina Capdevila
- Emergency Department, Bellvitge University Hospital, Department of Medicine, University of Barcelona, Bellvitge Biomedical Research Institute, L'Hospitalet de Llobregat, Barcelona, Catalonia, Spain
| | - Beatriz Rosón
- Department of Internal Medicine, Bellvitge University Hospital, University of Barcelona, Bellvitge Biomedical Research Institute, L'Hospitalet de Llobregat, Barcelona, Catalonia, Spain
| | - Xavier Corbella
- Department of Internal Medicine, Bellvitge University Hospital, University of Barcelona, Bellvitge Biomedical Research Institute, L'Hospitalet de Llobregat, Barcelona, Catalonia, Spain; Albert J. Jovell Institute of Public Health and Patients, Faculty of Medicine and Health Sciences, Universitat International de Catalunya, Barcelona, Catalonia, Spain
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Huang GC, Tibbles CD, Newman LR, Schwartzstein RM. Consensus of the Millennium Conference on Teaching High Value Care. TEACHING AND LEARNING IN MEDICINE 2016; 28:97-104. [PMID: 26787090 DOI: 10.1080/10401334.2015.1077132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
ISSUE Healthcare costs have spiraled out of control, yet students and residents may lack the knowledge and skills to provide high value care, which emphasizes the best possible care while reducing unnecessary costs. EVIDENCE Mainly national campaigns are aimed at physicians to reconsider their test ordering behaviors, identify overused diagnostics, and disseminate innovative practices. These efforts will fall short if principles of high value care are not incorporated across the spectrum of training for the next generation of physicians. IMPLICATIONS Consensus findings of an invitational conference of 7 medical school teams consisting of academic leaders included strategies for institutions to meaningfully incorporate high value care into their medical school, residency, and faculty development curricula.
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Affiliation(s)
- Grace C Huang
- a Center for Education, Carl J. Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center , Boston , Massachusetts , USA
| | - Carrie D Tibbles
- a Center for Education, Carl J. Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center , Boston , Massachusetts , USA
| | - Lori R Newman
- a Center for Education, Carl J. Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center , Boston , Massachusetts , USA
| | - Richard M Schwartzstein
- a Center for Education, Carl J. Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center , Boston , Massachusetts , USA
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The effect of transfers between health care facilities on costs and length of stay for pediatric burn patients. J Burn Care Res 2015; 36:178-83. [PMID: 25501777 DOI: 10.1097/bcr.0000000000000206] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Hospitals vary widely in the services they offer to care for pediatric burn patients. When a hospital does not have the ability or capacity to handle a pediatric burn, the decision often is made to transfer the patient to another short-term hospital. Transfers may be based on available specialty coverage for children; which adult and non-teaching hospitals may not have available. The effect these transfers have on costs and length of stay (LOS) has on pediatric burn patients is not well established and is warranted given the prominent view that pediatric hospitals are inefficient or more costly. The authors examined inpatient admissions for pediatric burn patients in 2003, 2006, and 2009 using the Kids' Inpatient Database, which is part of the Healthcare Cost and Utilization Project. ICD-9-CM codes 940 to 947 were used to define burn injury. The authors tested if transfer status was associated with LOS and total charges for pediatric burn patients, while adjusting for traditional risk factors (eg, age, TBSA, insurance status, type of hospital [pediatric vs adult; teaching vs nonteaching]) by using generalized linear mixed-effects modeling. A total of n = 28,777 children had a burn injury. Transfer status (P < .001) and TBSA (P < .001) was independently associated with LOS, while age, insurance status, and type of hospital were not associated with LOS. Similarly, transfer status (P < .001) and TBSA (P < .001) was independently associated with total charges, while age, insurance status, and type of hospital were not associated with total charges. In addition, the data suggest that the more severe pediatric burn patients are being transferred from adult and non-teaching hospitals to pediatric and teaching hospitals, which may explain the increased costs and LOS seen at pediatric hospitals. Larger more severe burns are being transferred to pediatric hospitals with the ability or capacity to handle these conditions in the pediatric population, which has a dramatic impact on costs and LOS. As a result, unadjusted, pediatric hospitals are seen as being inefficient in treating pediatric burns. However, since pediatric hospitals see more severe cases, after adjustment, type of hospital did not influence costs and LOS. TBSA and transfer status were the predictors studied that independently affect costs and LOS.
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Tartaglia KM, Kman N, Ledford C. Medical Student Perceptions of Cost-Conscious Care in an Internal Medicine Clerkship: A Thematic Analysis. J Gen Intern Med 2015; 30:1491-6. [PMID: 25931005 PMCID: PMC4579231 DOI: 10.1007/s11606-015-3324-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although as much as 87 % of all healthcare spending is directed by physicians, studies have demonstrated that they lack knowledge about the costs of medical care. Similarly, learners have not traditionally received instruction on cost-conscious care. OBJECTIVE To examine medical students' perceptions of healthcare delivery as it relates to cost consciousness DESIGN Retrospective qualitative analysis of medical student narratives PARTICIPANTS Third-year medical students during their inpatient internal medicine clerkship MAIN MEASURES Students completed a reflective exercise wherein they were asked to describe a scenario in which a patient experienced lack of attention to cost-conscious care, and were asked to identify solutions and barriers. We analyzed these reflections to learn more about students' awareness and perceptions regarding the practice of cost-conscious care within our medical center. KEY RESULTS Eighty students submitted the assignment between July and December 2012. The most common problems identified included unnecessary tests and treatments (n = 69) and duplicative tests and treatments (n = 20.) With regards to solutions, students described 82 scenarios, with 125 potential solutions identified. Students most commonly used discussion with the team (speak up, ask why) as the process they would use (n = 28) and most often wanted to focus lab testing (n = 38) as the intervention. The most common barriers to high-value care included increased time and effort (n = 19), ingrained practices (n = 17), and defensive medicine or fear of missing something (n = 18.) CONCLUSIONS Even with minimal clinical experience, medical students were able to identify instances of lack of attention to cost-conscious care as well as potential solutions. Although students identified the hierarchy in healthcare teams as a potential barrier to improving high value care, most students stated they would feel comfortable engaging the team in discussion. Future efforts to empower learners at all levels to question value decisions and to develop and implement solutions may result in improved healthcare.
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Affiliation(s)
- Kimberly M Tartaglia
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | - Nicholas Kman
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Cynthia Ledford
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Portuguese Family Physicians' Awareness of Diagnostic and Laboratory Test Costs: A Cross-Sectional Study. PLoS One 2015; 10:e0137025. [PMID: 26356625 PMCID: PMC4565683 DOI: 10.1371/journal.pone.0137025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 08/11/2015] [Indexed: 11/19/2022] Open
Abstract
Background Physicians’ ability to make cost-effective decisions has been shown to be affected by their knowledge of health care costs. This study assessed whether Portuguese family physicians are aware of the costs of the most frequently prescribed diagnostic and laboratory tests. Methods A cross-sectional study was conducted in a representative sample of Portuguese family physicians, using computer-assisted telephone interviews for data collection. A Likert scale was used to assess physician’s level of agreement with four statements about health care costs. Family physicians were also asked to estimate the costs of diagnostic and laboratory tests. Each physician’s cost estimate was compared with the true cost and the absolute error was calculated. Results One-quarter (24%; 95% confidence interval: 23%–25%) of all cost estimates were accurate to within 25% of the true cost, with 55% (95% IC: 53–56) overestimating and 21% (95% IC: 20–22) underestimating the true actual cost. The majority (76%) of family physicians thought they did not have or were uncertain as to whether they had adequate knowledge of diagnostic and laboratory test costs, and only 7% reported receiving adequate education. The majority of the family physicians (82%) said that they had adequate access to information about the diagnostic and laboratory test costs. Thirty-three percent thought that costs did not influence their decision to order tests, while 27% were uncertain. Conclusions Portuguese family physicians have limited awareness of diagnostic and laboratory test costs, and our results demonstrate a need for improved education in this area. Further research should focus on identifying whether interventions in cost knowledge actually change ordering behavior, in identifying optimal methods to disseminate cost information, and on improving the cost-effectiveness of care.
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Abstract
Treatment of pediatric burn patients is costly and may require long length of stay in the hospital (LOS). Establishing where these LOS and charges are highest is warranted. The current study investigated whether pediatric burn patients had higher total charges and longer LOS when seen at teaching hospitals, when compared with nonteaching hospitals. The study reviewed inpatient admissions for pediatric burn patients in 2003, 2006, and 2009 by using the Kids' Inpatient Database, which is part of the Healthcare Cost and Utilization Project. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 940-947 were used to define burn injury, LOS, total charges, and type of hospital. The authors tested for differences between the LOS and total charges between children seen at three types of hospitals (pediatric, nonpediatric/teaching, nonpediatric/nonteaching) while adjusting for traditional risk factors (eg age, total burn surface area) by using generalized linear mixed-effects modeling. A total of N=28,777 children had burn injuries (n=16,115, 56.0% seen at pediatric hospitals; n=9353, 32.5% seen at nonpediatric/teaching hospitals; and n=3309, 11.5% seen at nonpediatric/nonteaching hospitals). Pediatric burn patients seen at pediatric hospitals, unadjusted, have significantly longer LOS (5.54 days vs 4.25 days and 4.00 days, P<.001) and more total charges in 2009 dollars ($31,319 vs $24,413 and $21,499, P<.001). In addition, patients seen at pediatric hospitals had significantly more total burn surface area (P<.001), more comorbidities (P=.021), and were younger (P<.001). After adjusting for total burn surface area, number of comorbidities, and age, no differences existed between teaching and nonteaching hospitals for LOS (P=.481) or total charges (P=.758). Although pediatric burn patients may have increased LOS and total charges when seen at teaching hospitals, when taking an unadjusted perspective, this may be an artifact that teaching hospitals see pediatric burn patients who are younger, have more comorbidities, and have more total burn surface area. As such, after adjustment, type of hospital may have no influence on LOS and total charges.
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Moriates C, Dohan D, Spetz J, Sawaya GF. Defining competencies for education in health care value: recommendations from the University of California, San Francisco Center for Healthcare Value Training Initiative. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2015; 90:421-424. [PMID: 25354077 DOI: 10.1097/acm.0000000000000545] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Leaders in medical education have increasingly called for the incorporation of cost awareness and health care value into health professions curricula. Emerging efforts have thus far focused on physicians, but foundational competencies need to be defined related to health care value that span all health professions and stages of training. The University of California, San Francisco (UCSF) Center for Healthcare Value launched an initiative in 2012 that engaged a group of educators from all four health professions schools at UCSF: Dentistry, Medicine, Nursing, and Pharmacy. This group created and agreed on a multidisciplinary set of comprehensive competencies related to health care value. The term "competency" was used to describe components within the larger domain of providing high-value care. The group then classified the competencies as beginner, proficient, or expert level through an iterative process and group consensus. The group articulated 21 competencies. The beginner competencies include basic principles of health policy, health care delivery, health costs, and insurance. Proficient competencies include real-world applications of concepts to clinical situations, primarily related to the care of individual patients. The expert competencies focus primarily on systems-level design, advocacy, mentorship, and policy. These competencies aim to identify a standard that may help inform the development of curricula across health professions training. These competencies could be translated into the learning objectives and evaluation methods of resources to teach health care value, and they should be considered in educational settings for health care professionals at all levels of training and across a variety of specialties.
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Affiliation(s)
- Christopher Moriates
- Dr. Moriates is assistant clinical professor of medicine, University of California, San Francisco School of Medicine, San Francisco, California. Dr. Dohan is professor of health policy and social medicine, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco School of Medicine, San Francisco, California. Dr. Spetz is professor of health policy, Philip R. Lee Institute for Health Policy Studies, and associate director for research strategy, Center for the Health Professions, University of California, San Francisco School of Medicine, San Francisco, California. Dr. Sawaya is professor of obstetrics, gynecology and reproductive science, and of epidemiology and biostatistics, University of California, San Francisco School of Medicine, San Francisco, California
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Ilic D, Nordin RB, Glasziou P, Tilson JK, Villanueva E. A randomised controlled trial of a blended learning education intervention for teaching evidence-based medicine. BMC MEDICAL EDUCATION 2015; 15:39. [PMID: 25884717 PMCID: PMC4358913 DOI: 10.1186/s12909-015-0321-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 02/19/2015] [Indexed: 05/07/2023]
Abstract
BACKGROUND Few studies have been performed to inform how best to teach evidence-based medicine (EBM) to medical trainees. Current evidence can only conclude that any form of teaching increases EBM competency, but cannot distinguish which form of teaching is most effective at increasing student competency in EBM. This study compared the effectiveness of a blended learning (BL) versus didactic learning (DL) approach of teaching EBM to medical students with respect to competency, self-efficacy, attitudes and behaviour toward EBM. METHODS A mixed methods study consisting of a randomised controlled trial (RCT) and qualitative case study was performed with medical students undertaking their first clinical year of training in EBM. Students were randomly assigned to receive EBM teaching via either a BL approach or the incumbent DL approach. Competency in EBM was assessed using the Berlin questionnaire and the 'Assessing Competency in EBM' (ACE) tool. Students' self-efficacy, attitudes and behaviour was also assessed. A series of focus groups was also performed to contextualise the quantitative results. RESULTS A total of 147 students completed the RCT, and a further 29 students participated in six focus group discussions. Students who received the BL approach to teaching EBM had significantly higher scores in 5 out of 6 behaviour domains, 3 out of 4 attitude domains and 10 out of 14 self-efficacy domains. Competency in EBM did not differ significantly between students receiving the BL approach versus those receiving the DL approach [Mean Difference (MD)=-0.68, (95% CI-1.71, 0.34), p=0.19]. No significant difference was observed between sites (p=0.89) or by student type (p=0.58). Focus group discussions suggested a strong student preference for teaching using a BL approach, which integrates lectures, online learning and small group activities. CONCLUSIONS BL is no more effective than DL at increasing medical students' knowledge and skills in EBM, but was significantly more effective at increasing student attitudes toward EBM and self-reported use of EBM in clinical practice. Given the various learning styles preferred by students, a multifaceted approach (incorporating BL) may be best suited when teaching EBM to medical students. Further research on the cost-effectiveness of EBM teaching modalities is required.
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Affiliation(s)
- Dragan Ilic
- Department of Epidemiology & Preventive Medicine, School of Public Health & Preventive Medicine, Level 6, The Alfred Centre, 99 Commercial Rd, Melbourne, VIC, 3004, Australia.
| | - Rusli Bin Nordin
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University, Johor Bahru, Malaysia.
| | - Paul Glasziou
- Faculty of Health Sciences and Medicine, Bond University, Robina, Australia.
| | - Julie K Tilson
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, USA.
| | - Elmer Villanueva
- Gippsland Medical School, Monash University, Churchill, Australia.
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Zhong X, Wang P, Feng J, Hu W, Huang C. Novel Transparent Urinary Tract Simulator Improves Teaching of Urological Operation Skills at a Single Institution. Urol Int 2015; 95:38-43. [PMID: 25720440 DOI: 10.1159/000375129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Accepted: 01/09/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVE This randomized controlled study compared a novel transparent urinary tract simulator with the traditional opaque urinary tract simulator as an aid for efficiently teaching urological surgical procedures. METHODS Senior medical students were tested on their understanding of urological theory before and after lectures concerning urinary system disease. The students received operative training using the transparent urinary tract simulator (experimental group, n = 80) or the J3311 opaque plastic urinary tract simulator (control, n = 80), specifically in catheterization and retrograde double-J stent implantation. The operative training was followed by a skills test and student satisfaction survey. RESULTS The test scores for theory were similar between the two groups, before and after training. Students in the experimental group performed significantly better than those in the control group on the procedural skills test, and also had significantly better self-directed learning skills, analytical skills, and greater motivation to learn. CONCLUSION During the initial step of training, the novel transparent urinary tract simulator significantly improved the efficiency of teaching urological procedural skills compared with the traditional opaque device.
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Affiliation(s)
- Xiao Zhong
- Department of Urology, Second Affiliated Hospital, Third Military Medical University, Chongqing, PR China
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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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Brito-Zerón P, Nicolás-Ocejo D, Jordán A, Retamozo S, López-Soto A, Bosch X. Diagnosing unexplained fever: can quick diagnosis units replace inpatient hospitalization? Eur J Clin Invest 2014; 44:707-18. [PMID: 24920307 DOI: 10.1111/eci.12287] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 06/06/2014] [Indexed: 12/30/2022]
Abstract
BACKGROUND Outpatient quick diagnosis units (QDUs) have become an increasingly recognized alternative to hospitalization for the diagnosis of a number of potentially serious diseases. No study has prospectively evaluated the usefulness of QDU for the diagnosis of unexplained fever. MATERIALS AND METHODS We prospectively assessed patients referred to QDU due to fever of uncertain nature (FUN), defined as a temperature > 38 °C during at least 1 week and no diagnosis after a previous evaluation. We also evaluated consecutive patients with FUN who were hospitalized during the same period. QDU and hospital costs were analysed by micro-costing techniques. RESULTS We evaluated 176 QDU patients and 168 controls. QDU patients were younger and required fewer investigations than controls. QDU patients had higher prevalence of viral infections (36% vs. 8%, P < 0·001) and lower prevalence of bacterial infections (6% vs. 46%, P < 0·001) and malignancies (2% vs. 14%, P < 0·001). While time-to-diagnosis of QDU patients was longer than length-of-stay of controls (25·82 vs.12·89 days, P < 0·001), 56% of QDU patients only required up to two visits. Cost per QDU patient was €644·59, while it was €4404·64 per hospitalized patient. CONCLUSIONS QDU patients with FUN were younger and had less serious diseases than controls including more viral and less bacterial infections and fewer malignancies. Mainly owing to untimely diagnostic reports, time-to-diagnosis was longer in QDU patients. Cost-savings in QDU were substantial. Using objective tools to evaluate the condition severity and general health status of FUN patients could help decide the most appropriate setting for their diagnostic study.
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Affiliation(s)
- Pilar Brito-Zerón
- Department of Autoimmune Diseases, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
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Broadwater-Hollifield C, Gren LH, Porucznik CA, Youngquist ST, Sundwall DN, Madsen TE. Emergency physician knowledge of reimbursement rates associated with emergency medical care. Am J Emerg Med 2014; 32:498-506. [DOI: 10.1016/j.ajem.2014.01.044] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Revised: 01/23/2014] [Accepted: 01/24/2014] [Indexed: 10/25/2022] Open
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Bosch X, Moreno P, Ríos M, Jordán A, López-Soto A. Comparison of Quick Diagnosis Units and Conventional Hospitalization for the Diagnosis of Cancer in Spain: A Descriptive Cohort Study. Oncology 2012; 83:283-91. [DOI: 10.1159/000341658] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Accepted: 07/02/2012] [Indexed: 11/19/2022]
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Geraci SA, Thigpen SC. The fundamental need for relative value metrics in educational innovation. Am J Med 2011; 124:1086-9. [PMID: 22017786 DOI: 10.1016/j.amjmed.2011.07.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Revised: 05/21/2011] [Accepted: 07/18/2011] [Indexed: 11/24/2022]
Affiliation(s)
- Stephen A Geraci
- Department of Internal Medicine, University of Mississippi School of Medicine, Jackson, MS, USA.
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Tek Sehgal R, Gorman P. Internal medicine physicians' knowledge of health care charges. J Grad Med Educ 2011; 3:182-7. [PMID: 22655140 PMCID: PMC3184926 DOI: 10.4300/jgme-d-10-00186.1] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Revised: 01/17/2010] [Accepted: 01/26/2011] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Concerns over the rising costs of health care have increased interest in educating residents about the cost impact of medical decisions. While many programs educate residents about the effectiveness of care, little is known about how well residents and faculty know charges of diagnostic tests or both groups' interest in this topic. METHODS We surveyed internal medicine residents and faculty at an academic tertiary care hospital. Both groups rated their agreement with a series of statements about health care charges on a Likert scale of 1 (strongly disagree) to 9 (strongly agree), and they estimated the charges for 15 commonly ordered diagnostic tests. Estimates within 25% of the true charge were considered correct. The Wilcoxon rank sum test was used to compare responses between residents and faculty. RESULTS Seventy of 126 eligible participants (56%) returned surveys. Participants showed poor knowledge of health care charges but expressed a desire to learn more. Physicians also felt that cost-effectiveness should be considered when ordering diagnostic tests, although faculty members felt more strongly about this than did residents. In estimating the charges for diagnostic tests, less than a quarter of all responses were within 25% of the true charge. CONCLUSIONS Internal medicine physicians poorly estimate the charges for diagnostic tests but have a strong desire to improve their knowledge, suggesting a possible intervention to improve the cost-effectiveness of medical care.
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