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Adkins BD, Booth GS, Jacobs JW, Jones H, Mouslim MC, Henderson MA. Outpatient apheresis billing: A photopheresis model shows that hospital price transparency data remain difficult to interpret. Am J Clin Pathol 2023; 160:404-410. [PMID: 37265164 DOI: 10.1093/ajcp/aqad059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 04/26/2023] [Indexed: 06/03/2023] Open
Abstract
OBJECTIVES The US health care payment system is complex and difficult to interpret. Although federal regulations require that more data, in the form of charges and negotiated rates, be made available, compliance remains variable. We review chargemaster and negotiated rate values for extracorporeal photopheresis (ECP) to assess this variability. We sought to determine the availability of chargemaster and negotiated rates for health care consumers and to assess compliance and pricing among institutions using ECP as a model for apheresis billing. METHODS We obtained ECP chargemaster data and negotiated rates from 20 institutions. We analyzed the availability of ECP chargemaster data and compared values with a previously published historic cohort. We evaluated the availability of negotiated rates and determined relative reimbursement using charge to reimbursement ratios. We determined calculated fines for hospitals based on bed size. RESULTS Chargemaster availability increased from 2019 to 2022, though only 65% (13/20) of hospitals had both chargemaster and negotiated rate data. Chargemaster prices increased significantly from 2019 to 2022 (range, $3,586.83-$34,043.00). We reviewed 1,191 negotiated rates, with institutions averaging 93.6 different rates (SD, 189.5). Negotiated rates were variable, ranging from $3,586.83 to $34,043.00 per procedure. Reimbursement was higher among private insurers compared with reported Centers for Medicare & Medicaid Services negotiated rates. Of the 35% (7/20) that lacked chargemaster and negotiated rates, institutions faced an average annual fine of $1,430,800. CONCLUSIONS Despite recent financial penalties, ECP pricing data are often unavailable or inadequate. Current available resources are unlikely to benefit the average health care consumer who requires ECP.
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Affiliation(s)
- Brian D Adkins
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, US
| | - Garrett S Booth
- Department of Pathology, Microbiology & Immunology, Vanderbilt University Medical Center, Nashville, TN, US
| | - Jeremy W Jacobs
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, US
| | - Heather Jones
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, US
| | - Morgane C Mouslim
- The Hilltop Institute at the University of Maryland, Baltimore County, Baltimore, MD, US
| | - Morgan A Henderson
- The Hilltop Institute at the University of Maryland, Baltimore County, Baltimore, MD, US
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Hadley M, Jardaly A, Paul K, Ponce B, Wise B, Patt J, Templeton K. Teaching of Cost-Effective Care in Orthopaedic Surgery Residency Training: A Survey of Residency Programs in the US. JB JS Open Access 2023; 8:e22.00111. [PMID: 37255672 PMCID: PMC10226615 DOI: 10.2106/jbjs.oa.22.00111] [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: 06/01/2023] Open
Abstract
Costs of healthcare in the US continue to rise at rates that are unsustainable. Prior studies, most of which come from non-surgical specialties, indicate that a variety of strategies to teach this material are utilized but without consensus on best practices. No studies exist regarding the teaching of cost-effective care in orthopaedic residency training programs. The goal of this study was to assess the landscape in this area from the perspective of program leadership. Methods A survey was developed that was sent to orthopaedic residency program leadership via email through their interaction with the COERG. Additional programs were included to enhance diversity of responding programs. The survey, based on those published from other areas of medicine, included questions about the experiences of the respondents in learning about cost-effective care, as well as how faculty and residents learned about this topic. Results Seventy one percent (30) of respondents noted that their faculty did not receive formal training in cost-effective care, and education in this area was likely to come from the department, especially review of practice data (12, 44%). Only 19% (8) of respondents agreed with the statement that "the majority of teaching faculty in our program consistently model cost-effective healthcare to residents". Few of the programs (10, 24%) had formal curricula for residents regarding cost-effective care, and the primary mode of education in cost-effective care was through informal discussions with faculty (17, 43%). Few residents (3, 13%) were able to easily find the costs of tests or procedures. Discussion There is not consistent education in cost-effective care for orthopaedic surgery program leadership, faculty, or trainees. The results of this survey demonstrate a need for discussion of best practices, including increasing access to cost data at a local level, and engaging with the AOA, CORD, and the American Academy of Orthopaedic Surgeons more broadly in the development of standard education modules for faculty and residents, to improve the current and future delivery of cost-effective musculoskeletal care.
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Affiliation(s)
- Morgan Hadley
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Achraf Jardaly
- Department of Orthopaedic Surgery, St. Louis University, St. Louis, Missouri
| | - Kyle Paul
- Department of Orthopaedic Surgery, UT Health San Antonio, San Antonia, Texas
| | | | - Brent Wise
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Joshua Patt
- Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, North Carolina
| | - Kimberly Templeton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
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Stephens JR, Hall M, Markham JL, Tchou MJ, Cotter JM, Shah SS, Steiner MJ, Gay JC. Outcomes Associated With High- Versus Low-Frequency Laboratory Testing Among Hospitalized Children. Hosp Pediatr 2021; 11:563-570. [PMID: 33952575 DOI: 10.1542/hpeds.2020-005561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Previous pediatric studies have revealed substantial variation in laboratory testing for specific conditions, but clinical outcomes associated with high- versus low-frequency testing are unclear. We hypothesized that hospitals with high- versus low-testing frequency would have worse clinical outcomes. METHODS We conducted a multicenter retrospective cohort study of patients 0 to 18 years old with low-acuity hospitalizations in the years 2018-2019 for 1 of 10 common All Patient Refined Diagnosis Related Groups. We identified hospitals with high-, moderate-, and low-frequency testing for 3 common groups of laboratory tests: complete blood cell count, basic chemistry studies, and inflammatory markers. Outcomes included length of stay, 7- and 30-day emergency department revisit and readmission rates, and hospital costs, comparing hospitals with high- versus low-frequency testing. RESULTS We identified 132 391 study encounters across 44 hospitals. Laboratory testing frequency varied by hospital and condition. We identified hospitals with high- (13), moderate- (20), and low-frequency (11) laboratory testing. When we compared hospitals with high- versus low-frequency testing, there were no differences in adjusted hospital costs (rate ratio 0.89; 95% confidence interval 0.71-1.12), length of stay (rate ratio 0.98; 95% confidence interval 0.91-1.06), 7-day (odds ratio 0.99; 95% confidence interval 0.81-1.21) or 30-day (odds ratio 1.01; 95% confidence interval 0.82-1.25) emergency department revisit rates, or 7-day (odds ratio 0.84; 95% confidence interval 0.65-1.25) or 30-day (odds ratio 0.91; 95% confidence interval 0.76-1.09) readmission rates. CONCLUSIONS In a multicenter study of children hospitalized for common low-acuity conditions, laboratory testing frequency varied widely across hospitals, without substantial differences in outcomes. Our results suggest opportunities to reduce laboratory overuse across conditions and children's hospitals.
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Affiliation(s)
- John R Stephens
- North Carolina Children's Hospital and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina;
| | - Matt Hall
- Children's Hospital Association, Overland Park, Kansas
| | - Jessica L Markham
- Children's Mercy Hospital and University of Missouri-Kansas City, Kansas City, Missouri
| | - Michael J Tchou
- Children's Hospital Colorado and School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jillian M Cotter
- Children's Hospital Colorado and School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Samir S Shah
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio; and
| | - Michael J Steiner
- North Carolina Children's Hospital and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - James C Gay
- Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee
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Maghbouli N, Akbari Sari A, Asghari F. Cost-consciousness among Iranian internal medicine residents. MEDICAL TEACHER 2020; 42:463-468. [PMID: 32009508 DOI: 10.1080/0142159x.2019.1708292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Background: Study aimed at assessing residents' cost awareness and their attitude about health care costs.Methods: Internal medicine residents at teaching hospitals of Tehran University of Medical Sciences were surveyed during August-December 2016 using a researcher-made questionnaire comprising attitude statements and cost estimation of diagnostic and treatment items.Results: Eighty-nine residents completed the survey (response rate = 56.6%). The results indicate that less than one quarter (23.69%) of cost estimates were in the range of correct answers. The mean (SD) for correct estimation of medications (out of 8 scores), lab tests (out of 20 scores), and total (out of 35 scores) were 1.25 (0.96), 4.92 (0.27), and 7.97 (0.34), respectively. An analysis of variance showed that the level of residency was positively correlated with residents' correct cost estimation (F (3, 77)=9.98, p = 0.029). There was a significant positive correlation between age of residents with the correct estimate of medication prices (p = 0.018, r = 0.261).Conclusions: The internal medicine residents of Tehran University of Medical Sciences have poor knowledge of health care costs, including medications, diagnostic tests, and hospitalization costs. The results of this study explain the necessity of developing a training program for the transfer of cost information to physicians.
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Affiliation(s)
- Nastaran Maghbouli
- Department of Physical Medicine and Rehabilitation, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Akbari Sari
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Fariba Asghari
- Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Fischer KA, Walling A, Wenger N, Glaspy J. Cost health literacy as a physician skill-set: the relationship between oncologist reported knowledge and engagement with patients on financial toxicity. Support Care Cancer 2020; 28:5709-5715. [PMID: 32193693 DOI: 10.1007/s00520-020-05406-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 03/06/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Oncologists are increasingly encouraged to communicate with patients about cost; however, they may lack the cost health literacy required to effectively perform this task. METHODS We conducted a pilot survey of oncologists in an academic medical center to assess potential factors that may influence provider attitudes and practices related to financial toxicity. We assessed perceived provider knowledge of treatment costs, insurance coverage and co-pays, and financially focused resources. We then evaluated the relationship between perceived knowledge and reported engagement with issues of financial toxicity. RESULTS Of 45 respondents (85% response rate), 58% had changed treatment within the past year as a result of patient financial burden. On self-report, 36% discussed out-of-pocket costs with patients, 42% assessed patient financial distress, but only 20% felt they could intervene upon financial toxicity. Self-perceived awareness of cost health literacy concepts were low; only 16% reporting high out-of-pocket cost knowledge, 31-33% high insurance knowledge, and 8% high awareness of financial resources. Report of cost discussion was associated with greater perceived awareness of both out-of-pocket costs and insurance design. However, reported financial distress assessment was only associated with perceived insurance awareness, not perceived cost knowledge. Cost health literacy was not associated with an increased sense of being able to impact on financial toxicity. CONCLUSION Oncologists acknowledge deficits in knowledge and skills that may play a role in the discussion and management of financial toxicity. Some cost health literacy competencies appear to correlate with physician involvement with financial toxicity, suggesting that education on this topic may facilitate physician engagement.
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Affiliation(s)
- Katrina A Fischer
- Department of Medicine, Division of Hematology & Oncology, UCLA School of Medicine, 200 UCLA Medical Plaza, Suite 120, Los Angeles, CA, 90095, USA.
| | - Anne Walling
- Department of Medicine, Division of General Internal Medicine & Health Services Research, UCLA School of Medicine, Los Angeles, CA, USA
| | - Neil Wenger
- Department of Medicine, Division of General Internal Medicine & Health Services Research, UCLA School of Medicine, Los Angeles, CA, USA
| | - John Glaspy
- Department of Medicine, Division of Hematology & Oncology, UCLA School of Medicine, 200 UCLA Medical Plaza, Suite 120, Los Angeles, CA, 90095, USA
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El Halabi M, Bou Daher H, Rustom LBO, Marrache M, Ichkhanian Y, Kahil K, El Sayed M, Sharara AI. Clinical utility and economic burden of routine serum lipase determination in the Emergency Department. Int J Clin Pract 2019; 73:e13409. [PMID: 31456308 DOI: 10.1111/ijcp.13409] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 07/29/2019] [Accepted: 08/23/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Serum lipase is a rapid and reliable laboratory test central to diagnosing acute pancreatitis (AP). Routine use in the emergency department (ED) setting for all cases of abdominal pain or as part of a standard laboratory biochemical profile may lead to unnecessary expenses. AIM To examine the utility of serum lipase determination at a tertiary care centre ED. METHODS Retrospective cross-sectional study of ED patients having serum lipase determination over a 12-month period. Electronic medical records were reviewed for indication and interpretation leading to additional diagnostic imaging, specialist consultation, interventions or hospital admission. RESULTS A total of 24 133 adult patients visited the ED during the study period: 4976 (20.6%) had serum lipase determination, 614 (12.4%) had abnormal lipase, 130 of which (21.1%) were above the diagnostic threshold for acutre pancreatitis (AP) (>3× ULN). A total of 75 patients had confirmed AP (0.3% of all adult ED visits). The positive and negative predictive values of serum lipase (>3× ULN) for AP were 43.6% and 99.6%, respectively. One thousand eight hundred and ninety patients (38.0%) had no abdominal pain on history or physical examination. In this group, the total charge associated with lipase determination was $51 030 with 251 (13.3%) elevated lipase values triggering cross-sectional abdominal imaging in 61 (24.3%) patients and unwarranted gastroenterology consultation in three (1.2%) for an additional charge of $28 975. CONCLUSIONS Serum lipase is widely overutilised in the emergency setting resulting in unnecessary expenses and investigations. Evidence-based review of clinical guidelines and more restrictive testing can result in substantial cost savings and improved patient care.
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Affiliation(s)
- Maan El Halabi
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Halim Bou Daher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Division of Gastroenterology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Luma Basma O Rustom
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Division of Gastroenterology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Majd Marrache
- School of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Yervant Ichkhanian
- School of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Karine Kahil
- School of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mazen El Sayed
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ala I Sharara
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Division of Gastroenterology, American University of Beirut Medical Center, Beirut, Lebanon
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Tchou MJ, Hall M, Shah SS, Johnson DP, Schroeder AR, Antoon JW, Genies MC, Quinonez R, Miller CW, Shah SP, Brady PW. Patterns of Electrolyte Testing at Children's Hospitals for Common Inpatient Diagnoses. Pediatrics 2019; 144:e20181644. [PMID: 31171587 PMCID: PMC6615522 DOI: 10.1542/peds.2018-1644] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/11/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Overuse of laboratory testing contributes substantially to health care waste, downstream resource use, and patient harm. Understanding patterns of variation in hospital-level testing across common inpatient diagnoses could identify outliers and inform waste-reduction efforts. METHODS We conducted a multicenter retrospective cohort study of pediatric inpatients at 41 children's hospitals using administrative data from 2010 to 2016. Initial electrolyte testing was defined as testing occurring within the first 2 days of an encounter, and repeat testing was defined as subsequent testing within an encounter in which initial testing occurred. To examine if testing rates correlated across diagnoses at the hospital level, we compared risk-adjusted rates for gastroenteritis with a weighted average of risk-adjusted rates in other diagnosis cohorts. For each diagnosis, linear regression was performed to compare initial and subsequent testing. RESULTS In 497 719 patient encounters, wide variation was observed across hospitals in adjusted, initial, and repeat testing rates. Hospital-specific rates of testing in gastroenteritis were moderately to strongly correlated with the weighted average of testing in other conditions (initial: r = 0.63; repeat r = 0.83). Within diagnoses, higher hospital-level initial testing rates were associated with significantly increased rates of subsequent testing for all diagnoses except gastroenteritis. CONCLUSIONS Among children's hospitals, rates of initial and repeat electrolyte testing vary widely across 8 common inpatient diagnoses. For most diagnoses, hospital-level rates of initial testing were associated with rates of subsequent testing. Consistent rates of testing across multiple diagnoses suggest that hospital-level factors, such as institutional culture, may influence decisions for electrolyte testing.
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Affiliation(s)
- Michael J Tchou
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio;
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Samir S Shah
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David P Johnson
- Division of Hospital Medicine, Department of Pediatrics, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Alan R Schroeder
- Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, California
| | - James W Antoon
- Children's Hospital, University of Illinois, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
| | - Marquita C Genies
- Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland
| | - Ricardo Quinonez
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Christopher W Miller
- Division of Pediatric Inpatient Medicine, Department of Pediatrics, University of Utah, Salt Lake City, Utah; and
| | - Snehal P Shah
- Division of Hospitalist Medicine, Department of Pediatrics, Washington University in St Louis, St Louis, Missouri
| | - Patrick W Brady
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Hirota Y, Suzuki S, Ohira Y, Shikino K, Ikusaka M. The Effectiveness of Cost Reduction with Charge Displays on Test Ordering under the Health Insurance System in Japan: A Study Using Paper-based Simulated Cases for Residents and Clinical Fellows. Intern Med 2019; 58:187-193. [PMID: 30210103 PMCID: PMC6378163 DOI: 10.2169/internalmedicine.0738-17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective To determine whether or not displaying the cost of tests can help reduce charges on test ordering in Japan. Methods This study was conducted under the setting of a simulated first visit of an outpatient for general internal medicine in a secondary medical institution in Japan. We randomly assigned 27 residents and clinical fellows to Team A or B. The first half, without charges displayed on the ordering system, was designated the "non-display group," and the participants of Team A selected tests for each paper-based simulated case (Q1-Q14), while the participants of Team B selected tests for Q15-Q28. The second half, which had charges displayed, was designated the "display group," and the participants of Team A selected tests for Q15-Q28, while the participants of Team B selected tests for Q1-Q14. The main outcome measure was the difference in the cost of tests per paper-based simulated case between the non-display and display groups. Results The median (interquartile range) cost of tests per paper-based simulated case was 12,255 yen (5,040-23,695 yen) in the non-display group versus 9,425 yen (2,320-21,700 yen) in the display group, showing a decrease of 2,830 yen with charges being displayed (p=0.002). Conclusion Displaying the charges when ordering tests in paper-based simulated cases resulted in cost reduction. The adoption of this intervention may reduce health insurance costs under the health insurance system in Japan, which has features such as universal health coverage and universal access to care.
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Affiliation(s)
- Yusuke Hirota
- Department of General Medicine, Chiba University Hospital, Japan
| | - Shingo Suzuki
- Department of General Medicine, Chiba University Hospital, Japan
| | - Yoshiyuki Ohira
- Department of General Medicine, Chiba University Hospital, Japan
| | - Kiyoshi Shikino
- Department of General Medicine, Chiba University Hospital, Japan
| | - Masatomi Ikusaka
- Department of General Medicine, Chiba University Hospital, Japan
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Abraham L, Goyert N, Kagedan DJ, MacNeill A, Cleghorn MC, Hallet J, Quereshy FA, Coburn NG. Cost of open and laparoscopic distal gastrectomy: surgeon perceptions versus the reality of hospital spending. Can J Surg 2018; 61:392-397. [PMID: 30265642 DOI: 10.1503/cjs.014817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Rising health care costs have led to increasing focus on cost containment and accountability from health care providers. We sought to explore surgeon awareness of supply costs for open and laparoscopic distal gastrectomy. METHODS Surveys were sent in 2015 to surgeons at 8 academic hospitals in Toronto who performed distal gastrectomy for gastric adenocarcinoma. Respondents were asked to estimate the total cost, type and number of disposable equipment pieces required to perform open and laparoscopic distal gastrectomy. We determined the accuracy of estimates through comparisons with procedural invoices for distal gastrectomy performed between Jan. 1, 2011, and Dec. 31, 2015. All values are in 2015 Canadian dollars. RESULTS Of the 53 surveys sent out, 12 were completed (response rate 23%). Surgeon estimates of total supply costs ranged from $500 to $3000 and from $1500 to $5000 for open and laparoscopic cases, respectively. Estimated supply costs for requested equipment ranged from $464 to $2055 for open cases and from $1870 to $2960 for laparoscopic cases. Invoices for actual equipment yielded a mean of $821 (standard deviation $543) (range $89-$2613) for open cases and $2678 (standard deviation $958) (range $835-$4102) for laparoscopic cases. Estimates of total cost were within 25% of the median invoice total in 1 response (9%) for open cases and 3 (27%) of those for laparoscopic cases. CONCLUSION Respondents failed to accurately estimate equipment costs. The variation in true total costs and estimates of supply costs represents an opportunity for intraoperative cost minimization, efficient equipment selection and value-based purchasing arrangements.
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Affiliation(s)
- Liza Abraham
- From the Division of General Surgery, University of Toronto, Toronto, Ont. (Abraham, Hallet, Quereshy, Coburn); Cornerstone Research Group Inc, Burlington, Ont. (Goyert); the Roswell Park Comprehensive Cancer Center, Buffalo, NY (Kagedan); the Department of General Surgery, University of British Columbia, Vancouver, BC (MacNeill); the University Health Network, Toronto, Ont.(Cleghorn, Quereshy); and Sunnybrook Health Sciences Centre, Toronto, Ont. (Hallet, Coburn)
| | - Nik Goyert
- From the Division of General Surgery, University of Toronto, Toronto, Ont. (Abraham, Hallet, Quereshy, Coburn); Cornerstone Research Group Inc, Burlington, Ont. (Goyert); the Roswell Park Comprehensive Cancer Center, Buffalo, NY (Kagedan); the Department of General Surgery, University of British Columbia, Vancouver, BC (MacNeill); the University Health Network, Toronto, Ont.(Cleghorn, Quereshy); and Sunnybrook Health Sciences Centre, Toronto, Ont. (Hallet, Coburn)
| | - Daniel J Kagedan
- From the Division of General Surgery, University of Toronto, Toronto, Ont. (Abraham, Hallet, Quereshy, Coburn); Cornerstone Research Group Inc, Burlington, Ont. (Goyert); the Roswell Park Comprehensive Cancer Center, Buffalo, NY (Kagedan); the Department of General Surgery, University of British Columbia, Vancouver, BC (MacNeill); the University Health Network, Toronto, Ont.(Cleghorn, Quereshy); and Sunnybrook Health Sciences Centre, Toronto, Ont. (Hallet, Coburn)
| | - Andrea MacNeill
- From the Division of General Surgery, University of Toronto, Toronto, Ont. (Abraham, Hallet, Quereshy, Coburn); Cornerstone Research Group Inc, Burlington, Ont. (Goyert); the Roswell Park Comprehensive Cancer Center, Buffalo, NY (Kagedan); the Department of General Surgery, University of British Columbia, Vancouver, BC (MacNeill); the University Health Network, Toronto, Ont.(Cleghorn, Quereshy); and Sunnybrook Health Sciences Centre, Toronto, Ont. (Hallet, Coburn)
| | - Michelle C Cleghorn
- From the Division of General Surgery, University of Toronto, Toronto, Ont. (Abraham, Hallet, Quereshy, Coburn); Cornerstone Research Group Inc, Burlington, Ont. (Goyert); the Roswell Park Comprehensive Cancer Center, Buffalo, NY (Kagedan); the Department of General Surgery, University of British Columbia, Vancouver, BC (MacNeill); the University Health Network, Toronto, Ont.(Cleghorn, Quereshy); and Sunnybrook Health Sciences Centre, Toronto, Ont. (Hallet, Coburn)
| | - Julie Hallet
- From the Division of General Surgery, University of Toronto, Toronto, Ont. (Abraham, Hallet, Quereshy, Coburn); Cornerstone Research Group Inc, Burlington, Ont. (Goyert); the Roswell Park Comprehensive Cancer Center, Buffalo, NY (Kagedan); the Department of General Surgery, University of British Columbia, Vancouver, BC (MacNeill); the University Health Network, Toronto, Ont.(Cleghorn, Quereshy); and Sunnybrook Health Sciences Centre, Toronto, Ont. (Hallet, Coburn)
| | - Fayez A Quereshy
- From the Division of General Surgery, University of Toronto, Toronto, Ont. (Abraham, Hallet, Quereshy, Coburn); Cornerstone Research Group Inc, Burlington, Ont. (Goyert); the Roswell Park Comprehensive Cancer Center, Buffalo, NY (Kagedan); the Department of General Surgery, University of British Columbia, Vancouver, BC (MacNeill); the University Health Network, Toronto, Ont.(Cleghorn, Quereshy); and Sunnybrook Health Sciences Centre, Toronto, Ont. (Hallet, Coburn)
| | - Natalie G Coburn
- From the Division of General Surgery, University of Toronto, Toronto, Ont. (Abraham, Hallet, Quereshy, Coburn); Cornerstone Research Group Inc, Burlington, Ont. (Goyert); the Roswell Park Comprehensive Cancer Center, Buffalo, NY (Kagedan); the Department of General Surgery, University of British Columbia, Vancouver, BC (MacNeill); the University Health Network, Toronto, Ont.(Cleghorn, Quereshy); and Sunnybrook Health Sciences Centre, Toronto, Ont. (Hallet, Coburn)
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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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Eltorai AEM, Baird GL, Pangborn J, Eltorai AS, Antoci V, Paquette K, Connors K, Barbaria J, Smeals KJ, Riley B, Patel SA, Agarwal S, Healey TT, Ventetuolo CE, Sellke FW, Daniels AH. Financial Impact of Incentive Spirometry. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2018; 55:46958018794993. [PMID: 30175643 PMCID: PMC6122234 DOI: 10.1177/0046958018794993] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Despite largely unproven clinical effectiveness, incentive spirometry (IS) is widely used in an effort to reduce postoperative pulmonary complications. The objective of the study is to evaluate the financial impact of implementing IS. The amount of time nurses and RTs spend each day doing IS-related activities was assessed utilizing an online survey distributed to the relevant national nursing and respiratory therapists (RT) societies along with questionnaire that was prospectively collected every day for 4 weeks at a single 10-bed cardiothoracic surgery step-down unit. Cost of RT time to teach IS use to patients and cost of nurse time spent reeducating and reminding patients to use IS were used to calculate IS implementation cost estimates per patient. Per-patient cost of IS implementation ranged from $65.30 to $240.96 for a mean 9-day step-down stay. For the 566 patients who stayed in the 10-bed step-down in 2016, the total estimated cost of implementing IS ranged from $36 959.80 to $136 383.36. Using national survey workload data, per-patient cost of IS implementation costed $107.36 (95% confidence interval [CI], $97.88-$116.98) for a hospital stay of 4.5 days. For the 9.7 million inpatient surgeries performed annually in the United States, the total annual cost of implementing postoperative IS is estimated to be $1.04 billion (95% CI, $949.4 million-$1.13 billion). The cost of implementing IS is substantial. Further efficacy studies are necessary to determine whether the cost is justifiable.
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Affiliation(s)
- Adam E M Eltorai
- 1 The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Grayson L Baird
- 1 The Warren Alpert Medical School of Brown University, Providence, RI, USA.,2 Rhode Island Hospital, Providence, USA
| | - Joshua Pangborn
- 1 The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | | | - Valentin Antoci
- 1 The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | | | | | | | | | | | - Shyam A Patel
- 1 The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Saurabh Agarwal
- 1 The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Terrance T Healey
- 1 The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Corey E Ventetuolo
- 1 The Warren Alpert Medical School of Brown University, Providence, RI, USA.,2 Rhode Island Hospital, Providence, USA
| | - Frank W Sellke
- 1 The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Alan H Daniels
- 1 The Warren Alpert Medical School of Brown University, Providence, RI, USA
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12
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Herrmann LE, Tchou M, Beck J, Dewan M, Avery C, Schickedanz A, Quinonez R, Walker L. A Faculty Development Workshop for High-Value Care Education Across Clinical Settings. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2018; 14:10745. [PMID: 30800945 PMCID: PMC6346274 DOI: 10.15766/mep_2374-8265.10745] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 07/28/2018] [Indexed: 06/09/2023]
Abstract
Introduction Despite rising health care costs, trainees frequently do not receive formal high-value care (HVC) training. As medical education often occurs through informal learning, it is imperative that medical educators be prepared to teach HVC concepts across clinical settings. Methods This workshop was created to provide frameworks for teaching HVC across four pediatric educational settings: (1) case-based conferences, (2) inpatient rounding, (3) ambulatory visits, and (4) conversations with patients and families. Frameworks were developed based on literature review, content experts' knowledge, and internal assessment and feedback. The workshop was divided into two sections: a didactic overview of HVC education and interactive small-group sessions to practice application of the Toolkit for Teaching High-Value Care. At the end of the workshop, participants completed the Prescription for High-Value Care to create a personal action plan. Results This workshop has been presented at both national and local pediatric conferences. From over 89 evaluations (83% response rate), participants felt the workshop met objectives, served as a valuable use of their time, and provided useful resources. Evaluations elicited specific actions that participants gleaned from workshop content along with proposed behavior changes, such as creating HVC case-based conferences at their home institution and initiating more value-based discussions. Discussion This workshop has been successfully presented in both national and local settings and has been well received by participants. The workshop is targeted for clinical educators and aims to address the gap in faculty development for HVC education.
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Affiliation(s)
- Lisa E. Herrmann
- Assistant Professor, Department of Pediatrics, University of Cincinnati College of Medicine
- Assistant Professor, Division of Pediatric Hospital Medicine, Cincinnati Children's Hospital Medical Center
| | - Michael Tchou
- Pediatric Hospital Medicine Fellow, Cincinnati Children's Hospital Medical Center
| | - Jimmy Beck
- Assistant Professor, Division of General Pediatrics and Hospital Medicine, Seattle Children's Hospital
| | - Maya Dewan
- Assistant Professor, Department of Pediatrics, University of Cincinnati College of Medicine
- Assistant Professor, Division of Pediatric Critical Care, Cincinnati Children's Hospital Medical Center
| | - Carolyn Avery
- Assistant Professor, Department of Pediatrics, Section of Medicine-Pediatrics, Duke University Medical Center
| | - Adam Schickedanz
- Clinical Instructor, Department of Pediatrics, UCLA Medical Center
| | - Ricardo Quinonez
- Associate Professor, Department of Pediatrics, Baylor College of Medicine
| | - Lauren Walker
- Associate Professor, Department of Pediatrics, Baylor College of Medicine
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Gimbel RW, Pirrallo RG, Lowe SC, Wright DW, Zhang L, Woo MJ, Fontelo P, Liu F, Connor Z. Effect of clinical decision rules, patient cost and malpractice information on clinician brain CT image ordering: a randomized controlled trial. BMC Med Inform Decis Mak 2018. [PMID: 29530029 PMCID: PMC5848437 DOI: 10.1186/s12911-018-0602-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background The frequency of head computed tomography (CT) imaging for mild head trauma patients has raised safety and cost concerns. Validated clinical decision rules exist in the published literature and on-line sources to guide medical image ordering but are often not used by emergency department (ED) clinicians. Using simulation, we explored whether the presentation of a clinical decision rule (i.e. Canadian CT Head Rule - CCHR), findings from malpractice cases related to clinicians not ordering CT imaging in mild head trauma cases, and estimated patient out-of-pocket cost might influence clinician brain CT ordering. Understanding what type and how information may influence clinical decision making in the ordering advanced medical imaging is important in shaping the optimal design and implementation of related clinical decision support systems. Methods Multi-center, double-blinded simulation-based randomized controlled trial. Following standardized clinical vignette presentation, clinicians made an initial imaging decision for the patient. This was followed by additional information on decision support rules, malpractice outcome review, and patient cost; each with opportunity to modify their initial order. The malpractice and cost information differed by assigned group to test the any temporal relationship. The simulation closed with a second vignette and an imaging decision. Results One hundred sixteen of the 167 participants (66.9%) initially ordered a brain CT scan. After CCHR presentation, the number of clinicians ordering a CT dropped to 76 (45.8%), representing a 21.1% reduction in CT ordering (P = 0.002). This reduction in CT ordering was maintained, in comparison to initial imaging orders, when presented with malpractice review information (p = 0.002) and patient cost information (p = 0.002). About 57% of clinicians changed their order during study, while 43% never modified their imaging order. Conclusion This study suggests that ED clinician brain CT imaging decisions may be influenced by clinical decision support rules, patient out-of-pocket cost information and findings from malpractice case review. Trial registration NCT03449862, February 27, 2018, Retrospectively registered. Electronic supplementary material The online version of this article (10.1186/s12911-018-0602-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ronald W Gimbel
- Department of Public Health Sciences, Clemson University, 501 Edwards Hall, Clemson, SC, 29634-0745, USA.
| | - Ronald G Pirrallo
- Department of Emergency Medicine, Greenville Health System, Greenville, SC, USA
| | - Steven C Lowe
- Department of Radiology, Greenville Health System, Greenville, SC, USA
| | - David W Wright
- Department of Emergency Medicine, Emory University, Atlanta, GA, USA
| | - Lu Zhang
- Department of Public Health Sciences, Clemson University, 501 Edwards Hall, Clemson, SC, 29634-0745, USA
| | - Min-Jae Woo
- Department of Public Health Sciences, Clemson University, 501 Edwards Hall, Clemson, SC, 29634-0745, USA
| | - Paul Fontelo
- Lister Hill National Center for Biomedical Communication, National Library of Medicine, Bethesda, MD, USA
| | - Fang Liu
- Lister Hill National Center for Biomedical Communication, National Library of Medicine, Bethesda, MD, USA
| | - Zachary Connor
- Department of Public Health Sciences, Clemson University, 501 Edwards Hall, Clemson, SC, 29634-0745, USA.,Department of Radiology, Greenville Health System, Greenville, SC, USA
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14
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Sklar DP, Hemmer PA, Durning SJ. Medical Education and Health Care Delivery: A Call to Better Align Goals and Purposes. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2018; 93:384-390. [PMID: 28930760 DOI: 10.1097/acm.0000000000001921] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The transformation of the U.S. health care system is under way, driven by the needs of an aging population, rising health care spending, and the availability of health information. However, the speed and effectiveness of the transformation of health care delivery will depend, in large part, upon engagement of the health professions community and changes in clinicians' practice behaviors. Current efforts to influence practice behaviors emphasize changes in the health payment system with incentives to move from fee-for-service to alternative payment models.The authors describe the potential of medical education to augment payment incentives to make changes in clinical practice and the importance of aligning the purpose and goals of medical education with those of the health care delivery system. The authors discuss how curricular and assessment changes and faculty development can align medical education with the transformative trends in the health care delivery system. They also explain how the theory of situated cognition offers a shared conceptual framework that could help address the misalignment of education and clinical care. They provide examples of how quality improvement, health care innovation, population care management, and payment alignment could create bridges for joining health care delivery and medical education to meet the health care reform goals of a high-performing health care delivery system while controlling health care spending. Finally, the authors illustrate how current payment incentives such as bundled payments, value-based purchasing, and population-based payments can work synergistically with medical education to provide high-value care.
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Affiliation(s)
- David P Sklar
- D.P. Sklar is distinguished professor emeritus, University of New Mexico School of Medicine, Albuquerque, New Mexico, and editor-in-chief, Academic Medicine. P.A. Hemmer is professor of medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland. S.J. Durning is professor of medicine and pathology, Uniformed Services University of the Health Sciences, Bethesda, Maryland, and deputy editor for research, Academic Medicine
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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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16
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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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17
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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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King BC, DiPace J, Naifeh M, Hammad H, Gerber LM, Abramson E. Pediatric Training Faculty and Resident Perceptions on Teaching High-Value, Cost-Conscious Care: A Multi-Institutional Study. Hosp Pediatr 2017; 7:547-552. [PMID: 28838948 DOI: 10.1542/hpeds.2017-0037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND AND OBJECTIVES High-value, cost-conscious care (HVCCC) is care that promotes optimal patient outcomes while reducing unnecessary costs. Teaching to promote HVCCC is essential, yet little research has assessed the dual perspectives of residents and faculty on this topic. Our aim was to investigate pediatric resident and faculty perspectives of HVCCC training and role modeling to more effectively promote curriculum and faculty development on this subject. METHODS Pediatric residents and teaching faculty in 2 academic medical centers were surveyed during the 2015-2016 academic year. Questions addressed comfort with HVCCC, current teaching practices, barriers to teaching HVCC, and desired curriculum. Descriptive statistics were used to summarize data, and Fisher's exact or χ2 tests were used to assess for associations between responses. Institutional review board approval was obtained at both participating institutions. RESULTS We received responses from 51% of faculty (128 of 249) and 60% of residents (73 of 123). Most faculty and residents agreed that HVCCC training is important, but only 26% of residents (18 of 69) felt comfortable practicing HVCCC. Faculty and residents identified lack of training or knowledge (50%, 61 of 121 and 53%, 37 of 70, respectively) and lack of hospital support (73%, 88 of 121 and 69%, 47 of 68, respectively) as the largest barriers. Of residents, >85% (60 of 69) reported a lack of attending physician role modeling. Most faculty (83%, 102 of 123) desired faculty development. CONCLUSIONS Residents and faculty agree that HVCCC is important and that training institutions have a responsibility to address it. However, most residents were not comfortable with HVCCC. Faculty development in HVCCC as well as hospital support for access to pricing data will be key for programs to develop effective resident training in this area.
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Affiliation(s)
- Brian C King
- Departments of Pediatrics, and
- Department of Neonatology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas; and
| | | | - Monique Naifeh
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Hoda Hammad
- Healthcare Policy and Research, New York-Presbyterian Hospital/Weill Cornell Medical College, New York City, New York
| | - Linda M Gerber
- Healthcare Policy and Research, New York-Presbyterian Hospital/Weill Cornell Medical College, New York City, New York
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VanGalder K, Mersfelder TL, VanLangen K. Pharmacists' Knowledge of the Cost of Laboratory Testing. Hosp Pharm 2017; 52:357-360. [PMID: 28804152 DOI: 10.1177/0018578717715357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: The objective of this study was to ascertain baseline knowledge of pharmacists and pharmacy residents concerning the cost of laboratory tests for monitoring medications, and to determine whether an educational session delivered to pharmacy residents improves their knowledge of these costs. Methods: An online survey was provided to pharmacists and pharmacy residents, testing their knowledge of 15 common laboratory tests used to monitor the safety and efficacy of medications. One of the researchers presented a lecture to all pharmacy residents that detailed individual laboratory costs; after that, the researchers delivered a follow-up survey to assess the effectiveness of the educational session. Results: Baseline knowledge of pharmacists showed that greater than 64% of the responses were more than 30% away from the actual cost of the laboratory test for all 15 tests. Baseline knowledge of pharmacy residents showed that greater than 58% of the responses were more than 30% away from the actual cost of the laboratory test for each individual test. Although there was no statistically significant improvement in individual cost prediction after the educational session, 2 laboratory values showed improvement in margins of error post intervention: alanine aminotransferase/aspartate aminotransferase and lipids (P = .008 and .014, respectively). Conclusions: Pharmacists and pharmacy residents poorly predicted the costs of common laboratory tests. A brief lecture discussing the cost of laboratory tests demonstrated minor improvement in pharmacy residents' knowledge of the costs reviewed. Pharmacists need to be educated on the cost of laboratory tests to better understand the profession's contribution to health care expenditures.
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Steen AJ, Mann JA, Carlberg VM, Kimball AB, Musty MJ, Simpson EL. Understanding the cost of dermatologic care: A survey study of dermatology providers, residents, and patients. J Am Acad Dermatol 2017; 76:609-617. [PMID: 28189269 DOI: 10.1016/j.jaad.2016.11.049] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 11/15/2016] [Accepted: 11/19/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Aaron J Steen
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire; Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Julianne A Mann
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire; Department of Dermatology, Oregon Health & Science University, Portland, Oregon; Division of Dermatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Valerie M Carlberg
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon; Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Alexa B Kimball
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Michael J Musty
- Department of Mathematics, Dartmouth College, Hanover, New Hampshire
| | - Eric L Simpson
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon.
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Al Zamil MA, Arafa MA. Awareness of Surgeons in Saudi Arabia About the Surgical Costs and Investigations: Multicenter Study. JOURNAL OF SURGICAL EDUCATION 2017; 74:187-190. [PMID: 27692809 DOI: 10.1016/j.jsurg.2016.08.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 07/16/2016] [Accepted: 08/28/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To investigate the level of knowledge and awareness of the cost of the currently used blood investigations, imaging studies, admission cost, and surgical instrument among surgeons in Saudi Arabia. DESIGN It was a cross-section study conducted in Riyadh city, the capital of Saudi Arabia. SETTING Multihealth centers including main University hospital, Military hospitals, and Ministry of health hospitals. All surgeons in the health facilities were invited to participate in the study. A questionnaire has been formulated, and distributed to all participants. It was composed of 3 sections such as: demographic data, awareness about the cost, and physicians' perception about the cost and the attitude of their institution toward cost practice. RESULT Totally, 296 participants were enrolled in the study. More than half of the respondents were females (53.3%). Nearly two-thirds were in the young age group (30-40 years), 41.2% were residents. Only 4.4%, 3.4%, 8.4%, and 3.7% of the surgeons were fully aware of the cost of blood investigations, imaging studies, surgical instruments/prosthesis, and the medication that they prescribe, respectively. Most of them mentioned that their institute neither encourages them to consider a cost-effective practice (86.9%) nor monitor how cost effective is their practice (86.2%). CONCLUSION Surgeon's knowledge and awareness about the cost of different medical procedures were insufficient. Surgeons' knowledge and attitudes about costs of care can be improved through the use of audit and feedback with patient cost and charge data, which could be attained through the inclusion of audit and feedback as part of a curriculum teaching.
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Affiliation(s)
| | - Mostafa A Arafa
- Cancer Research Chair, Faculty of Medicine, King Saud University, Riyadh, Saudi Arabia.
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Pahwa A, Cayea D, Bertram A, Apfel A, Miller C, Van Wagoner N, Willig J, Karani R, Ashar B. Student perceptions of high-value care education in internal medicine clerkships. J Hosp Med 2017; 12:102-103. [PMID: 28182806 DOI: 10.12788/jhm.2689] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Amit Pahwa
- Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Danelle Cayea
- Division of Geriatric Medicine and Gerontology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amanda Bertram
- Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ariella Apfel
- Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chad Miller
- Department of Medicine, Tulane University School of Medicine, New Orleans, LA, USA
| | - Nick Van Wagoner
- Division of Infectious Disease, University of Alabama School of Medicine, Birmingham, AL, USA
| | - James Willig
- Division of Infectious Disease, University of Alabama School of Medicine, Birmingham, AL, USA
| | - Reena Karani
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bimal Ashar
- Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Tainter CR, Gentges JA, Thomas SH, Burns BD. Can Emergency Medicine Residents Predict Cost of Diagnostic Testing? West J Emerg Med 2016; 18:159-162. [PMID: 28116030 PMCID: PMC5226753 DOI: 10.5811/westjem.2016.10.31234] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 08/12/2016] [Accepted: 10/24/2016] [Indexed: 11/11/2022] Open
Abstract
Introduction Diagnostic testing represents a significant portion of healthcare spending, and cost should be considered when ordering such tests. Needless and excessive spending may occur without an appreciation of the impact on the larger healthcare system. Knowledge regarding the cost of diagnostic testing among emergency medicine (EM) residents has not previously been studied. Methods A survey was administered to 20 EM residents from a single ACGME-accredited three-year EM residency program, asking for an estimation of patient charges for 20 commonly ordered laboratory tests and seven radiological exams. We compared responses between residency classes to evaluate whether there was a difference based on level of training. Results The survey completion rate was 100% (20/20 residents). We noted significant discrepancies between the median resident estimates and actual charge to patient for both laboratory and radiological exams. Nearly all responses were an underestimate of the actual cost. The group median underestimation for laboratory testing was $114, for radiographs $57, and for computed tomography exams was $1,058. There was improvement in accuracy with increasing level of training. Conclusion This pilot study demonstrates that EM residents have a poor understanding of the charges burdening patients and health insurance providers. In order to make balanced decisions with regard to diagnostic testing, providers must appreciate these factors. Education regarding the cost of providing emergency care is a potential area for improvement of EM residency curricula, and warrants further attention and investigation.
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Affiliation(s)
- Christopher R Tainter
- University of California, San Diego, Department of Emergency Medicine and Department of Anesthesiology, Division of Critical Care, San Diego, California
| | - Joshua A Gentges
- The University of Oklahoma, Tulsa, Department of Emergency Medicine, Tulsa, Oklahoma
| | - Stephen H Thomas
- Weill Cornell College of Medicine in Qatar and Hamad Medical Corporation, Department of Emergency Medicine, Doha, Qatar
| | - Boyd D Burns
- The University of Oklahoma, Tulsa, Department of Emergency Medicine, Tulsa, Oklahoma
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Vijayasarathi A, Duszak R, Gelbard RB, Mullins ME. Knowledge of the Costs of Diagnostic Imaging: A Survey of Physician Trainees at a Large Academic Medical Center. J Am Coll Radiol 2016; 13:1304-1310. [DOI: 10.1016/j.jacr.2016.05.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 05/03/2016] [Accepted: 05/09/2016] [Indexed: 02/04/2023]
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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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Kruger JF, Chen AH, Rybkin A, Leeds K, Guzman D, Vittinghoff E, Goldman LE. Displaying radiation exposure and cost information at order entry for outpatient diagnostic imaging: a strategy to inform clinician ordering. BMJ Qual Saf 2016; 25:977-985. [PMID: 26740494 DOI: 10.1136/bmjqs-2015-004242] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 11/30/2015] [Accepted: 12/01/2015] [Indexed: 11/03/2022]
Abstract
BACKGROUND Displaying radiation exposure and cost information at electronic order entry may encourage clinicians to consider the value of diagnostic imaging. METHODS An urban safety-net health system displayed radiation exposure information for CT and cost information for CT, MRI and ultrasound on an electronic referral system for outpatient ordering. We assessed whether there were differences in numbers of outpatient CT scans and MRIs per month relative to ultrasounds before and after the intervention, and evaluated primary care clinicians' responses to the intervention. RESULTS There were 23 171 outpatient CTs, 15 052 MRIs and 43 266 ultrasounds from 2011 to 2014. The ratio of CTs to ultrasounds decreased by 15% (95% CI 9% to 21%), from 58.2 to 49.6 CTs per 100 ultrasounds; the ratio of MRIs to ultrasounds declined by 13% (95% CI 7% to 19%), from 37.5 to 32.5 per 100. Of 300 invited, 190 (63%) completed the web-based survey in 17 clinics. 154 (81%) noticed the radiation exposure information and 158 (83.2%) noticed the cost information. Clinicians believed radiation exposure information was more influential than cost information: when unsure clinically about ordering a test (radiation=69.7%; cost=46.4%), when a patient wanted a test not clinically indicated (radiation=77.5%; cost=54.8%), when they had a choice between imaging modalities (radiation=77.9%; cost=66.6%), in patient care discussions (radiation=71.9%; cost=43.2%) and in trainee discussions (radiation=56.5%; cost=53.7%). Resident physicians and nurse practitioners were more likely to report that the cost information influenced them (p<0.05). CONCLUSIONS Displaying radiation exposure and cost information at order entry may improve clinician awareness about diagnostic imaging safety risks and costs. More clinicians reported the radiation information influenced their clinical practice.
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Affiliation(s)
- Jenna F Kruger
- Center for Quality and Clinical Effectiveness, Lucile Packard Children's Hospital at Stanford, Palo Alto, California, USA
| | - Alice Hm Chen
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Alex Rybkin
- Radiology and Biomedical Imaging, UCSF, San Francisco, California, USA
| | - Kiren Leeds
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - David Guzman
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | | | - L Elizabeth Goldman
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
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How Much Do Common Imaging Studies Cost? A Nationwide Survey of Radiology Trainees. AJR Am J Roentgenol 2015; 205:929-35. [DOI: 10.2214/ajr.14.14167] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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DeQuesada IM, Chokshi FH, Mullins ME, Duszak R. Practice Management and Health Policy Education in Radiology: An Emerging Imperative. J Am Coll Radiol 2015; 12:1085-92. [DOI: 10.1016/j.jacr.2015.04.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 04/02/2015] [Indexed: 10/23/2022]
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Ryskina KL, Smith CD, Weissman A, Post J, Dine CJ, Bollmann K, Korenstein D. U.S. Internal Medicine Residents' Knowledge and Practice of High-Value Care: A National Survey. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2015; 90:1373-1379. [PMID: 26083399 DOI: 10.1097/acm.0000000000000791] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
PURPOSE To determine U.S. internal medicine (IM) residents' knowledge of, attitudes toward, and self-reported practice of high-value care (HVC), or care that balances the benefits, harms, and costs of tests and treatments. METHOD The authors conducted a cross-sectional survey of U.S. IM residents who took the Internal Medicine In-Training Examination in October 2012. They used multivariable mixed-effects models to examine the relationships between self-reported knowledge and practice of HVC and both exposure to HVC teaching and the care intensity of the training hospital (based on a composite age-sex-race-illness standardized measure of hospital days and inpatient physician visits by Medicare recipients). RESULTS Of 21,617 residents who received the survey, 18,102 (83.7%) completed it. Self-reported HVC practices varied: 4,187 of 17,633 respondents (23.7%) agreed that they "share estimated costs of tests and treatments with patients"; 15,549 of 17,626 (88.2%) agreed that they "incorporate patients' values and concerns into clinical decisions." Discussions about balancing the benefits, harms, and costs of treatments with faculty during patient care at least a few times a week were reported by 7,103 of 17,704 respondents (40.1%) and were associated with all self-reported HVC practices. The training hospital's care intensity was inversely associated with self-reported incorporation of costs and patient values into clinical decisions but not with other self-reported behaviors. CONCLUSIONS U.S. IM residents reported varying HVC knowledge and practice. Faculty discussions of HVC during patient care correlated with such knowledge and practice and may represent an opportunity to improve residents' competency in providing value-based care.
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Affiliation(s)
- Kira L Ryskina
- K.L. Ryskina is general internal medicine fellow, Division of General Internal Medicine, and fellow, Leonard Davis Institute of Health Economics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.C.D. Smith is director of clinical programs development and senior physician educator, American College of Physicians, Philadelphia, Pennsylvania.A. Weissman is research center director, American College of Physicians, Philadelphia, Pennsylvania.J. Post is assistant professor, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota.C.J. Dine is assistant professor, Division of Pulmonary and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.K. Bollmann is assistant professor, Department of Medicine, Banner Good Samaritan Medical Center, Phoenix, Arizona.D. Korenstein is clinical member, Memorial Hospital at Memorial Sloan Kettering Cancer Center, New York, New York
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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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Broadwater-Hollifield C, Madsen TE, Porucznik CA, Sundwall DN, Youngquist ST, Vlasic K, Gren LH. Predictors of patient adherence to follow-up recommendations after an ED visit. Am J Emerg Med 2015; 33:1368-73. [PMID: 26279393 DOI: 10.1016/j.ajem.2015.07.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 07/14/2015] [Accepted: 07/16/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND It is unclear whether factors identified during the emergency department (ED) visit predict noncompliance with ED recommendations. STUDY OBJECTIVE We sought to determine predictors of adherence to medical recommendations after an ED visit. METHODS We conducted a prospective, observational study at a single urban medical center. Eligible ED patients provided baseline demographic data as well as information regarding insurance status, whether they had a primary care physician (PCP), and the impact of cost of care on their ability to follow medical recommendations. Patients were contacted at least 1 week after the ED visit and answered questions regarding adherence to medical recommendations. RESULTS Four hundred twenty-two patients agreed to participate in the study. At follow-up, 89.7% of patients reported that they had complied with recommendations made during the ED visit. Patients who were adherent to follow-up recommendations were more likely to have a primary care provider (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.1-6.1), have an annual income of greater than $35000 (OR, 2.9; 95% CI, 1.2-7.2), and report a non-Hispanic ethnicity or race (OR, 2.8; 95% CI, 1.1-7.1). Individuals who reported that cost "sometimes" or "always" impacts their ability to follow their physician's recommendations were significantly less likely to comply with ED recommendations (OR, 2.7; 95% CI, 1.3-5.6). CONCLUSION Individuals who reported that cost affects their ability to follow their physician's recommendations and those who did not have a PCP were less likely to follow ED recommendations. Identification of predictors of noncompliance during the ED visit may aid in ensuring compliance with ED recommendations.
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Affiliation(s)
- Camille Broadwater-Hollifield
- Department of Family and Preventive Medicine-Division of Public Health, University of Utah School of Medicine, Salt Lake City, UT
| | - Troy E Madsen
- Department of Surgery-Division of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Christina A Porucznik
- Department of Family and Preventive Medicine-Division of Public Health, University of Utah School of Medicine, Salt Lake City, UT
| | - David N Sundwall
- Department of Family and Preventive Medicine-Division of Public Health, University of Utah School of Medicine, Salt Lake City, UT
| | - Scott T Youngquist
- Department of Surgery-Division of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Kajsa Vlasic
- Department of Surgery-Division of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Lisa H Gren
- Department of Family and Preventive Medicine-Division of Public Health, University of Utah School of Medicine, Salt Lake City, UT
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Information system technologies' role in augmenting dermatologists' knowledge of prescription medication costs. Int J Med Inform 2015; 84:1076-84. [PMID: 26228652 DOI: 10.1016/j.ijmedinf.2015.06.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Revised: 06/18/2015] [Accepted: 06/29/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Despite the recent rising costs of once affordable dermatologic prescription medications, a survey measuring dermatologists' attitudes, beliefs, and knowledge of the cost of drugs they commonly prescribe has not been conducted. Awareness of drug costs is hindered by a lack of access to data about the prices of medicines. No surveys of physicians have addressed this issue by proposing new information system technologies that augment prescription medication price transparency and measuring how receptive physicians are to using these novel solutions in their daily clinical practice. Our research aims to investigate these topics with a survey of physicians in dermatology. METHODS Members of the North Carolina Dermatology Association were contacted through their electronic mailing list and asked to take an online survey. The survey asked several questions about dermatologists' attitudes and beliefs about drug costs. To measure their knowledge of prescription medications, the National Average Drug Acquisition Cost was used as an authoritative price that was compared to the survey takers' price estimates of drugs commonly used in dermatology. Physicians' willingness to use four distinct information system technologies that increase drug price transparency was also assessed. RESULTS Dermatologists believe drug costs are an important factor in patient care and believe access to price information would allow them to provide a higher quality of care. Dermatologists' knowledge of the costs of medicines they commonly prescribe is poor, but they want to utilize information system technologies that increase access to drug pricing information. CONCLUSIONS There is an unmet demand for information system technologies which increase price transparency of medications in dermatology. Physicians and IT professionals have the opportunity to create novel information systems that can be utilized to help guide cost conscious clinical decision making.
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Nationwide variation in outcomes and cost of laparoscopic procedures. Surg Endosc 2015; 30:934-46. [PMID: 26139490 DOI: 10.1007/s00464-015-4328-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 06/09/2015] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Healthcare systems and surgeons are under increasing pressure to provide high-quality care for the lowest possible cost . This study utilizes national data to examine the outcomes and costs of common laparoscopic procedures based on hospital type and location. METHODS The National Inpatient Sample was queried from 2008 to 2011 for five laparoscopic procedures: colectomy (LC), inguinal hernia repair, ventral hernia repair (LVHR), Nissen fundoplication (NF), and cholecystectomy (LCh). Outcomes, including complication rate and inpatient mortality, were stratified by region and hospital type. Both univariate and multivariate regression analyses were performed using regression-based survey methods; risk-adjusted mean costs for hospital were calculated after adjusting for patient characteristics. RESULTS In univariate analysis, the rates of minor complications varied significantly between geographic regions for LCh, LC, NF, and LVHR (p < 0.05). Though LCh and LVHR had statistical variation between regions for rates of major complications (p < 0.05), all regions were equivalent in rates of inpatient mortality for the procedures (p > 0.05). Rural and urban centers had similar rates of complications (p > 0.05), except for higher rates of major complications following IHR and LC in rural centers (p < 0.02) and following Nissen fundoplication in urban facilities(p < 0.0003). Though urban centers were more expensive for all procedures (p < 0.0001), mortality was similar between groups (p > 0.05). For hospital ownership, private investor-owned facilities were substantially more expensive (p < 0.0001), but had no significant differences in complications compared to other hospital types (p > 0.05). In multivariate analysis, while patient factors helped explain differences between outcome differences in different hospital types and locations, in general, the difference in cost remained statistically significant between hospitals. CONCLUSION Though patient demographics and characteristics accounted for some differences in postoperative outcomes after common laparoscopic procedures, higher cost of care was not associated with better outcomes or more complex patients.
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Bade K, Hoogerbrug J. Awareness of surgical costs: a multicenter cross-sectional survey. JOURNAL OF SURGICAL EDUCATION 2015; 72:23-27. [PMID: 25112174 DOI: 10.1016/j.jsurg.2014.06.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 06/16/2014] [Accepted: 06/26/2014] [Indexed: 06/03/2023]
Abstract
BACKGROUND Resource scarcity continues to be an important problem in modern surgical practice. Studies in North America and Europe have found that medical professionals have limited understanding of the costs of medical care. No cost awareness studies have been undertaken in Australasia or specifically focusing on the surgical team. This study determined the cost of a range of commonly used diagnostic tests, procedures, and hospital resources associated with care of the surgical patient. The surgical teams' awareness of these costs was then assessed in a multicenter cross-sectional survey. METHODS In total, 14 general surgical consultants, 14 registrars, and 25 house officers working in three New Zealand hospitals were asked to estimate the costs of 14 items commonly associated with patient care. Cost estimations were considered correct if within 25% plus or minus of the actual cost. Accuracy was assessed by calculating the median, mean, and absolute percentage discrepancy. RESULTS A total of 57 surveys were completed. Of which, four were incomplete and were not included in the analysis. Cost awareness was generally poor, and members of the surgical team were rarely able to estimate the costs to within 25%. The mean absolute percentage error was 0.87 (95% CI: 0.58-1.18) and underestimates were most common. There was no significant difference in estimate accuracy between consultants, registrars, or house officers, or between consultants working in both public/private practice compared with those working in public practice alone. CONCLUSION There is poor awareness of surgical costs among consultant surgeons, registrars, and junior physicians working in Australasia.
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Affiliation(s)
- Kim Bade
- Tauranga Hospital, Tauranga, New Zealand
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Sharp AL, Cobb EM, Dresden SM, Richardson DK, Sabbatini AK, Sauser K, Kocher KE. Understanding the value of emergency care: a framework incorporating stakeholder perspectives. J Emerg Med 2014; 47:333-42. [PMID: 24881891 DOI: 10.1016/j.jemermed.2014.04.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 12/16/2013] [Accepted: 04/22/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND In the face of escalating spending, measuring and maximizing the value of health services has become an important focus of health reform. Recent initiatives aim to incentivize high-value care through provider and hospital payment reform, but the role of the emergency department (ED) remains poorly defined. OBJECTIVES To achieve an improved understanding of the value of emergency care, we have developed a framework that incorporates the perspectives of stakeholders in the delivery of health services. METHODS A pragmatic review of the literature informed the design of this framework to standardize the definition of value in emergency care and discuss outcomes and costs from different stakeholder perspectives. The viewpoint of patient, provider, payer, health system, and society is each used to assess value for emergency medical conditions. RESULTS We found that the value attributed to emergency care differs substantially by stakeholder perspective. Potential targets to improve ED value may be aimed at improving outcomes or controlling costs, depending on the acuity of the clinical condition. CONCLUSION The value of emergency care varies by perspective, and a better understanding is achieved when specific outcomes and costs can be identified, quantified, and measured. Using this framework can help stakeholders find common ground to prioritize which costs and outcomes to target for research, quality improvement efforts, and future health policy impacting emergency care.
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Affiliation(s)
- Adam L Sharp
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan; Robert Wood Johnson Foundation Clinical Scholars Program, University of Michigan, Ann Arbor, Michigan; Research and Evaluation Department, Kaiser Permanente Southern California, Pasadena, California
| | - Enesha M Cobb
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan; Robert Wood Johnson Foundation Clinical Scholars Program, University of Michigan, Ann Arbor, Michigan
| | - Scott M Dresden
- Department of Emergency Medicine, Northwestern University, Chicago, Illinois; Center for Healthcare Studies, Northwestern University, Chicago, Illinois
| | - Derek K Richardson
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Amber K Sabbatini
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
| | - Kori Sauser
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan; Robert Wood Johnson Foundation Clinical Scholars Program, University of Michigan, Ann Arbor, Michigan; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Keith E Kocher
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy (CHOP), University of Michigan, Ann Arbor, Michigan
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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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Eriksen II, Melberg HO, Bringedal B. Norwegian physicians' knowledge of the prices of pharmaceuticals: a survey. PLoS One 2013; 8:e75218. [PMID: 24040402 PMCID: PMC3770612 DOI: 10.1371/journal.pone.0075218] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2012] [Accepted: 08/13/2013] [Indexed: 11/18/2022] Open
Abstract
The objectives of this study are to measure physicians’ knowledge of the prices of pharmaceuticals, and investigate whether there are differences in knowledge of prices between groups of physicians. This article reports on a survey study of physicians’ knowledge of the prices of pharmaceuticals conducted on a representative sample of Norwegian physicians in the autumn of 2010. The importance of physicians’ knowledge of costs derives from their influence on total spending and allocation of limited health-care resources. Physicians are important drivers in the effort to contain costs in health care, but only if they have the knowledge needed to choose the most cost-effective treatment options. A survey was sent to 1 543 Norwegian physicians, asking them for price estimates and their opinions on the importance of considering the cost of treatment to society as a decision factor when treating their patients. This article deals with a subsection in which the physicians were asked to estimate the price of five pharmaceuticals: simvastatin, alendronate (Fosamax), infliximab (Remicade), natalizumab (Tysabri) and escitalopram (Cipralex). The response rate was 65%. For all the five pharmaceuticals, more than 50% and as many as 83% gave responses that differed more than 50% from the actual drug price. The price of more expensive pharmaceuticals was underestimated, while the opposite was the case for less expensive medicines. The data show that physicians in general have poor knowledge of the prices of the pharmaceuticals they offer their patients. However, the physicians who frequently deal with a drug have better knowledge of its price than those who do not handle a medication as often. The data also suggest that those physicians who agree that cost of care to society is an important decision factor have better knowledge of drug prices.
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Affiliation(s)
- Ida Iren Eriksen
- University of Oslo, Department of Health Management and Health Economics, Oslo, Norway
- * E-mail:
| | - Hans Olav Melberg
- University of Oslo, Department of Health Management and Health Economics, Oslo, Norway
| | - Berit Bringedal
- LEFO, the Institute for Studies of the Medical Profession, Oslo, Norway
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Patel MS, Volpp KG. Leveraging insights from behavioral economics to increase the value of health-care service provision. J Gen Intern Med 2012; 27:1544-7. [PMID: 22549296 PMCID: PMC3475818 DOI: 10.1007/s11606-012-2050-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Revised: 03/09/2012] [Accepted: 03/15/2012] [Indexed: 10/28/2022]
Abstract
United States health expenditures continue to escalate at unsustainable rates. A recent movement around increasing price transparency has been suggested as a way of reducing the rate of increase in expenditures, with legislative efforts taking place at both the state and federal level. While this seems on the surface like a good idea, simply providing information on prices to physicians, particularly trainees, may not achieve the type of large changes in practice patterns that proponents expect. The manner in which price transparency is implemented will likely play a significant role in its effectiveness as an intervention. In this article, the authors review efforts of transparency and default options from other contexts and leverage insights from behavioral economics to provide recommendations for increasing the likelihood that price transparency will lead to physicians weighing the relative value of interventions.
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Affiliation(s)
- Mitesh S Patel
- Department of Medicine, Hospital of the University of Pennsylvania, 3400 Spruce St., 100 Centrex, Philadelphia, PA, 19104, USA.
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