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Navanandan N, McNulty MC, Suresh K, Freeman J, Scherer LD, Tyler A. Factors Associated With Clinician Self-Reported Resource Use in Acute Care and Ambulatory Pediatrics. Clin Pediatr (Phila) 2022; 62:329-337. [PMID: 36199256 PMCID: PMC10073349 DOI: 10.1177/00099228221128074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The objective of this study is to determine predictors of resource use among pediatric providers for common respiratory illnesses. We surveyed pediatric primary care, emergency department (ED)/urgent care (UC), and hospital medicine providers at a free-standing children's hospital system. Five clinical vignettes assessed factors affecting resource use for upper respiratory infections, bronchiolitis, and pneumonia, including provider-type, practice location, tolerance to uncertainty, and medical decision-making behaviors. The response rate was 75.3% (168/223). The ED/UC and primary care providers had higher vignette scores, indicating higher resource use, compared with inpatient providers; advanced practice providers (APPs) had higher vignette scores compared with physicians. In multivariate analysis, being an ED/UC provider, an APP, and greater concern for bad outcomes were associated with higher vignette scores. Overall, provider type and location of practice may predict resource use for children with respiratory illnesses. Interventions targeted at test-maximizing providers may improve quality of care and reduce resource burden.
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Affiliation(s)
- Nidhya Navanandan
- Section of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora, CO, USA.,Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Monica C McNulty
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO, USA
| | - Krithika Suresh
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO, USA.,Department of Biostatistics and Informatics, University of Colorado School of Public Health, Aurora, CO, USA
| | - Julia Freeman
- Section of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora, CO, USA.,Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Laura D Scherer
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO, USA.,Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Amy Tyler
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.,Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO, USA.,Section of Pediatric Hospital Medicine, Children's Hospital of Colorado, Aurora, CO, USA
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Seltz LB, Nathaniel E, Ball A, Jimenez S, Tchou M. Pediatric Residents' Experiences With High-Value Care at an Academic Children's Hospital. J Grad Med Educ 2022; 14:80-88. [PMID: 35222825 PMCID: PMC8848867 DOI: 10.4300/jgme-d-21-00665.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 10/28/2021] [Accepted: 12/01/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The Accreditation Council for Graduate Medical Education mandates residents incorporate cost considerations into patient care. However, resident experiences with high-value care (HVC) in the clinical setting have not been well described. OBJECTIVE To explore pediatric residents' experiences with HVC and its facilitators and barriers. METHODS We performed a qualitative study with a grounded theory epistemology of pediatric residents recruited by email at a large academic children's hospital. We conducted focus groups (n=3) and interviews (n=7) between February and September 2020 using a semi-structured guide. Data were analyzed using the constant comparative method. Codes were built using an iterative approach and organized into thematic categories. Sampling continued until saturation was reached. RESULTS Twenty-two residents participated. Residents' value-based health care decisions occurred in a complex learning environment. Due to limited experience, residents feared missing diagnoses, which contributed to perceived overtesting. Resident autonomy, with valuable experiential learning, supported and hindered HVC. Informal teaching occurred through patient care discussions; however, cost information was lacking. Practice of HVC varied by clinical setting with greater challenges on high acuity and subspecialty services. For children with medical complexity, identifying family concerns and goals of care improved value. Family experience/demands influenced resident health care decisions, contributing to high- and low-value care. Effective collaboration among health care team members was crucial; residents often felt pressured following perceived low-value recommendations from consultants. CONCLUSIONS Resident HVC learning and practice is influenced by multiple factors in a complex clinical learning environment.
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Affiliation(s)
- L. Barry Seltz
- All authors are with Children's Hospital Colorado and University of Colorado School of Medicine
- L. Barry Seltz, MD, is a Pediatric Hospitalist and Associate Residency Program Director
| | - Emma Nathaniel
- All authors are with Children's Hospital Colorado and University of Colorado School of Medicine
- Emma Nathaniel, MD, was a PGY-3 Resident at the time of the study and is now Pediatric Hospitalist
| | - Alexis Ball
- All authors are with Children's Hospital Colorado and University of Colorado School of Medicine
- Alexis Ball, MD, was a PGY-2 Resident at the time of the study and is now a General Pediatrician
| | - Sheilah Jimenez
- All authors are with Children's Hospital Colorado and University of Colorado School of Medicine
- Sheilah Jimenez, is a Professional Research Assistant
| | - Michael Tchou
- All authors are with Children's Hospital Colorado and University of Colorado School of Medicine
- Michael Tchou, MD, MSc, is a Pediatric Hospitalist
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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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Arbuckle MR, Barkil-Oteo A, Asghar-Ali AA, Stern DA. Training in High-Value, Cost-Effective Care: a Curriculum for Psychiatry Residents. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2020; 44:330-334. [PMID: 32212097 DOI: 10.1007/s40596-020-01199-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 02/04/2020] [Indexed: 06/10/2023]
Affiliation(s)
- Melissa R Arbuckle
- Columbia University Irving Medical Center and the New York State Psychiatric Institute, New York, NY, USA.
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Tseng EK, Mukerji G, Weinerman A, Fuller J, McLeod A, Wong BM, Kuper A, Stroud LS. Choosing Words Wisely: Residents' Use of Rhetorical Appeals in Conversations About Unnecessary Tests. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2020; 95:275-282. [PMID: 31517680 DOI: 10.1097/acm.0000000000002980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE To characterize how residents employ rhetorical appeals (i.e., the strategic use of communication to achieve specifiable goals) when discussing unnecessary diagnostic tests with patients. METHOD In 2015, senior hematology residents from 10 Canadian universities participating in a national formative objective structured clinical examination (OSCE) completed a resource stewardship communication station. In this communication scenario, a standardized patient (SP) portrayed a patient requesting unnecessary thrombophilia testing following early pregnancy loss. The authors performed a thematic analysis of audio transcripts using a qualitative description approach to identify residents' rhetorical appeals to logic (rational appeals), credibility, and emotion. RESULTS For persuasive communication, residents (n = 27) relied primarily on rational appeals that fit into 3 categories (with themes) focused on medical evidence (poor utility, professional guidelines and recommendations), avoidance of harm (insurance implications, unnecessary or potentially harmful interventions, patient anxiety), and reassurance to patient (normalizing, clinical pretest probability, criteria for reconsidering testing). Appeals to credibility and emotion were rarely used. CONCLUSIONS In an OSCE setting, residents relied predominantly on rational appeals when engaging SPs in conversations about unnecessary tests. These observations yield insights into how recent emphasis within residency education on appropriate test utilization may manifest when residents put recommendations into practice in conversations with patients. This study's framework of rational appeals may be helpful in designing communication curricula about unnecessary testing. Future studies should explore rhetoric about unnecessary testing in the clinical environment, strategies to teach and coach residents leading these conversations, and patients' preferences and responses to different appeals.
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Affiliation(s)
- Eric K Tseng
- E.K. Tseng is assistant professor, Department of Medicine, University of Toronto, and staff physician, Division of Hematology/Oncology, St. Michael's Hospital, Toronto, Ontario, Canada. G. Mukerji is assistant professor, Department of Medicine, University of Toronto, and staff physician, Division of Endocrinology, Women's College Hospital, Toronto, Ontario, Canada. A. Weinerman is assistant professor, Department of Medicine, University of Toronto, and staff physician, Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. J. Fuller is assistant professor, Department of History and Philosophy of Science, University of Pittsburgh, Pittsburgh, Pennsylvania, and research associate, African Centre for Epistemology and Philosophy of Science, University of Johannesburg, Johannesburg, South Africa. A. McLeod is assistant professor, Department of Medicine, University of Toronto, and staff physician, Division of Hematology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. B.M. Wong is associate professor, Department of Medicine, and associate director, Centre for Quality Improvement and Patient Safety, University of Toronto, and staff physician, Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. A. Kuper is associate professor, Department of Medicine, and education scientist, Wilson Centre for Education, University of Toronto, and staff physician, Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. L.S. Stroud is associate professor, Department of Medicine, and centre researcher, Wilson Centre for Education, University of Toronto, and staff physician, Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Girdwood SCT, Sellas MN, Courter JD, Liberio B, Tchou MJ, Herrmann LE, Dewan ML, Statile AM, Unaka NI. Improving the Transition of Intravenous to Enteral Antibiotics in Pediatric Patients with Pneumonia or Skin and Soft Tissue Infections. J Hosp Med 2020; 15:10-15. [PMID: 31339843 DOI: 10.12788/jhm.3253] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Despite national recommendations for early transition to enteral antimicrobials, practice variability has existed at our hospital. OBJECTIVE The aim of this study was to increase the proportion of enterally administered antibiotic doses for Pediatric Hospital Medicine patients aged >60 days admitted for uncomplicated community-acquired pneumonia or skin and soft tissue infections from 44% to 75% in eight months. METHODS This quality improvement study was conducted at a large, urban, academic children's hospital. The study population included Hospital Medicine patients aged >60 days with diagnoses of pneumonia or skin and soft tissue infections. Interventions included education on intravenous and enteral antibiotic charge differentials, documentation of transition plan, structured discussions of transition criteria, and real-time identification of failures with feedback. Our process measure was the total number of enteral antibiotic doses divided by all antibiotic doses in patients receiving enteral medications on the same day. An annotated statistical process control chart tracked the impact of interventions on the administration route of antibiotic doses over time. Additional outcome measures included antimicrobial costs per patient encounter using average wholesale prices and length of stay. RESULTS The percentage of enterally administered antibiotic doses increased from 44% to 80% within eight months. Antimicrobial costs per patient encounter and the associated standard deviation of costs for our target diagnoses decreased by 70% and 84%, respectively. Average length of stay did not change. CONCLUSIONS Standardized communication about criteria for transition from intravenous to enteral antibiotics can lead to earlier transitions for patients with pneumonia or skin and soft tissue infections, subsequently reducing costs and prescribing variability.
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Affiliation(s)
- Sonya C Tang Girdwood
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Maria N Sellas
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pharmacy, Nationwide Children's Hospital, Columbus, Ohio
| | - Joshua D Courter
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Brianna Liberio
- Pediatric Residency Program, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michael J Tchou
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Section of Hospital Medicine, Children's Hospital Colorado, Aurora, Colorado
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Lisa E Herrmann
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Maya L Dewan
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Angela M Statile
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Pediatric Residency Program, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Ndidi I Unaka
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Pediatric Residency Program, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
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Shah BJ, Jou JH. Incorporating High Value Care Into Gastroenterology Fellowship Training. Clin Gastroenterol Hepatol 2020; 18:11-13. [PMID: 31676358 DOI: 10.1016/j.cgh.2019.10.040] [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: 02/07/2023]
Affiliation(s)
- Brijen J Shah
- Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Janice H Jou
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon
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