Implementation of a High-Value Care Curriculum for General Surgery Residents

Abstract

Healthcare expenditures account for more than 3.5 trillion dollars annually with estimates of nearly one-half being wasteful. High-value care (HVC) balances the benefits, harms, and costs of healthcare. Since 2012, the American College of Physicians and Accreditation Council for Graduate Medical Education developed a HVC curriculum and incorporated HVC into milestones for medicine residents. However, currently no HVC curriculum or milestones exist for general surgery residents (GSR). We sought to implement a HVC curriculum for GSR and evaluate awareness and attitudes toward HVC, hypothesizing improved resident awareness and attitudes toward HVC without affecting patient outcomes. A prospective comparison between pre-HVC curriculum (7/1/2017-11/30/2017) and post-HVC curriculum (2/1/2018-6/30/2018) was performed. The curriculum included 6 didactic lectures with group discussions. A 14-question Likert-scale survey evaluating awareness, use of, and attitudes toward HVC was performed on all GSR. Additional patient outcomes were collected for all trauma patients cared for during the study period. Bivariate analysis using Mann-Whitney U test was performed. There were 38/38 GSR respondents (100% response rate) for the pre-HVC survey and 35/38 (92.1% response rate) for the post-HVC survey. More post-HVC respondents somewhat agreed (34.3% vs 5.3%) and less strongly disagreed (31.4% vs 52.6%) with improved knowledge of where to find costs of labs/imaging/treatment (p = 0.02) compared to the pre-HVC group. More post-HVC respondents strongly agreed they balanced the benefit of clinical care with costs and harm when treating patients (25.7% vs 21.1%; p = 0.01). More post-HVC respondents strongly agreed they customized care plans to incorporate patients' values/concerns after implementation of the curriculum (51.4% vs 23.7%, p = 0.0006). From 3254 trauma patients studied, 1722 (52.9%) were pre-HVC and 1532 (47.1%) post-HVC patients. There was no difference between the pre- and post-HVC-curriculum trauma patients in terms of demographics and outcomes such as mortality (3.6% vs 2.4%, p = 0.07) and median length of stay (2 vs 2 days, p = 0.6). Implementation of a HVC curriculum for GSR led to improved awareness regarding healthcare costs and customizing decision plans for patients, with no difference in trauma patient outcomes. Future research incorporating cost data is needed; however, with implementation of the 2020 general surgery milestones (addition of Systems-Based Practice-3), this curriculum could prove beneficial.