High-value Cost-conscious Care Research Articles

Implementing high-value, cost-conscious care: experiences of Irish doctors and the role of education in facilitating this approach

BackgroundAdopting high-value, cost-conscious care (HVCCC) principles into medical education is growing in importance due to soaring global healthcare costs and the recognition that efficient care can enhance patient outcomes and control costs. Understanding the current opportunities and challenges doctors face concerning HVCCC in healthcare systems is crucial to tailor education to doctors’ needs. Hence, this study aimed to explore medical students, junior doctors, and senior doctors’ experiences with HVCCC, and to seek senior doctors’ viewpoints on how education can foster HVCCC in clinical environments.MethodsUsing a mixed-methods design, our study involved a cross-sectional survey using the Maastricht HVCCC-Attitude Questionnaire (MHAQ), with a subset of consultants engaging in semi-structured interviews. Descriptive analysis provided insights into both categorical and non-categorical variables, with differences examined across roles (students, interns, junior doctors, senior doctors) via Kruskal-Wallis tests, supplemented by two-group analyses using Mann-Whitney U testing. We correlated experience with MHAQ scores using Spearman’s rho, tested MHAQ’s internal consistency with Cronbach’s alpha, and employed thematic analysis for the qualitative data.ResultsWe received 416 responses to the survey, and 12 senior doctors participated in the semi-structured interviews. Overall, all groups demonstrated moderately positive attitudes towards HVCCC, with more experienced doctors exhibiting more favourable views, especially about integrating costs into daily practice. In the interviews, participants agreed on the importance of instilling HVCCC values during undergraduate teaching and supplementing it with a formal curriculum in postgraduate training. This, coupled with practical knowledge gained on-the-job, was seen as a beneficial strategy for training doctors.ConclusionsThis sample of medical students and hospital-based doctors display generally positive attitudes towards HVCCC, high-value care provision, and the integration of healthcare costs, suggesting receptiveness to future HVCCC training among students and doctors. Experience is a key factor in HVCCC, so early exposure to these concepts can potentially enhance practice within existing healthcare budgets.

Factors Associated with Medical Students' Attitudes About Cost-Conscious Care: A Mixed-Methods Multi-school Study.

Because physician practices contribute to national healthcare expenditures, initiatives aimed at educating physicians about high-value cost-conscious care (HVCCC) are important. Prior studies suggest that the training environment influences physician attitudes and behaviors towards HVCCC. To explore the relationship between medical student experiences and HVCCC attitudes. Quantitative and qualitative analysis of a multi-institutional survey. Medical students from nine US medical schools. A 44-item survey that included the Maastricht HVCCC Attitudes Questionnaire, a validated tool for assessing HVCCC attitudes, was administered electronically. Attitudinal domains of high-value care (HVC), cost incorporation (CI), and perceived drawbacks (PD) were compared using one-way ANOVA among students with a range of exposures. Open text responses inviting participants to reflect on their attitudes were analyzed using classical content analysis. A total of 740 students completed the survey (response rate 15%). Students pursuing a "continuity-oriented" specialty held more favorable attitudes towards HVCCC than those pursuing "technique-oriented" specialties (HVC sub-score = 3.20 vs. 3.06; p = 0.005, CI sub-score = 2.83 vs. 2.74; p < 0.001). Qualitative analyses revealed personal, educational, and professional experiences shape students' HVCCC attitudes, with similar experiences interpreted differently leading to both more and less favorable attitudes. Students pursuing specialties with longitudinal patient contact may be more enthusiastic about practicing high-value care. Life experiences before and during medical school shape these attitudes, and complex interactions between these forces drive student perceptions of HVCCC.

Residents' Reflections on Cost-Conscious Care after International Health Electives: A Single-Center Qualitative Study.

Estimates suggest 30% of health care expenditures are wasteful. This has led to increased educational interventions in graduate medical education (GME) training aimed to prepare residents for high value, cost-conscious practice. International health electives (IHE) are widely available in GME training and may be provide trainees a unique perspective on principles related to high value, cost-conscious care (HVCCC). The purpose of this study was to explore how trainee reflections on IHE experiences offer insight into HVCCC. The authors conducted an applied thematic analysis of narrative reflective reports of GME trainees' IHE experiences to characterize their perceptions of HVCCC. The Mayo International Health Program (MIHP) supports residents and fellows from all specialties across all Mayo Clinic sites. We included 546 MIHP participants from 2001 to 2020. The authors collected post-elective narrative reports from all MIHP participants. Reflections were coded and themes were organized into model for transformative learning during IHEs, focusing on HVCCC. GME trainees across 24 different medical specialties participated in IHEs in 73 different countries. Three components of transformative learning were identified: disorienting dilemma, critical reflection, and commitment to behavior change. Within the component of critical reflection, three topics related to HVCCC were identified: cost transparency, resource stewardship, and reduced fear of litigation. Transformation was demonstrated through reflection on future behavioral change, including cost-aware practice, stepwise approach to health care, and greater reliance on clinical skills. IHEs provide rich experiences for transformative learning and reflection on HVCCC. These experiences may help shape trainees' ideology of and commitment to HVCCC practices.

ICRE Abstracts: Quality Improvement

ICRE Abstracts: Quality Improvement

High-Value, Cost-Conscious Care Attitudes in the Graduate Medical Education Learning Environment: Various Stakeholder Attitudes That Residents Misjudge

BackgroundTraining residents in delivering high-value, cost-conscious care (HVCCC) is crucial for a sustainable healthcare. A supportive learning environment is key. Yet, stakeholders’ attitudes toward HVCCC in residents’ learning environment are unknown.ObjectiveWe aimed to measure stakeholders’ HVCCC attitudes in residents’ learning environment, compare these with resident perceptions of their attitudes, and identify factors associated with attitudinal differences among each stakeholder group.DesignWe conducted a cross-sectional survey across the Netherlands between June 2017 and December 2018.ParticipantsParticipants were 312 residents, 305 faculty members, 53 administrators, and 1049 patients from 66 (non)academic hospitals.Main MeasuresRespondents completed the Maastricht HVCCC Attitude Questionnaire (MHAQ), containing three subscales: (1) high-value care, (2) cost incorporation, (3) perceived drawbacks. Additionally, resident respondents estimated the HVCCC attitudes of other stakeholders, and answered questions on job demands and resources. Univariate and multivariate analyses were used to analyze data.Key ResultsAttitudes differed on all subscales: faculty and administrators reported more positive HVCCC attitudes than residents (p ≤ 0.05), while the attitudes of patients were less positive (p ≤ 0.05). Residents underestimated faculty’s (p < 0.001) and overestimated patients’ HVCCC attitudes (p < 0.001). Increasing age was, among residents and faculty, associated with more positive attitudes toward HVCCC (p ≤ 0.05). Lower perceived health quality was associated with less positive attitudes among patients (p < 0.001). The more autonomy residents perceived, the more positive their HVCCC attitude (p ≤ 0.05).ConclusionsAttitudes toward HVCCC vary among stakeholders in the residency learning environment, and residents misjudge the attitudes of both faculty and patients. Faculty and administrators might improve their support to residents by more explicitly sharing their thoughts and knowledge on HVCCC and granting residents autonomy in clinical practice.

Program on high value cost-conscious education in intensive care: Educational program on prediction of outcome and cost awareness on Intensive Care admission

BackgroundIntensive Care (ICU) involves extended and long lasting support of vital functions and organs. However, current training programs of ICU residents mainly focus on extended support of vital functions and barely involve training on cost-awareness and outcome. We incorporated an educational program on high-value cost-conscious care for residents and fellows on our ICU and measured the effect of education.MethodsA cohort study with factorial survey design, in which ICU residents and fellows were asked to evaluate clinical vignettes, was performed on the mixed surgical-medical ICU of the Amsterdam University Medical Centre. Residents were offered an educational program focusing on outcome and costs of ICU care. Before and after the program they filled out a questionnaire, which consisted of 23 vignettes, in which known predictors of outcome of community acquired pneumonia (CAP), pancreatitis, acute respiratory distress syndrome (ARDS) and cardiac arrest were presented, together with varying patient factors (age, body mass index (BMI), acute kidney failure (AKI) and haemato-oncological malignancy). Participants were asked to either admit the patient or estimate mortality.ResultsBMI, haemato-oncological malignancy and severity of pancreatitis were discriminative for admission to ICU in clinical vignettes on pancreatitis and CAP. After education, only severity of pancreatitis was judged as discriminative. Before the intervention only location of cardiac arrest (in- vs out of hospital) was distinctive for mortality, afterwards this changed to presence of haemato-oncological malignancy.ConclusionWe incorporated an educational program on high-value cost-conscious care in the training of ICU physicians. Based on our vignette study, we conclude that the improvement of knowledge of costs and prognosis after this program was limited.

A new instrument to measure high value, cost-conscious care attitudes among healthcare stakeholders: development of the MHAQ

BackgroundResidents have to learn to provide high value, cost-conscious care (HVCCC) to counter the trend of excessive healthcare costs. Their learning is impacted by individuals from different stakeholder groups within the workplace environment. These individuals’ attitudes toward HVCCC may influence how and what residents learn. This study was carried out to develop an instrument to reliably measure HVCCC attitudes among residents, staff physicians, administrators, and patients. The instrument can be used to assess the residency-training environment.MethodThe Maastricht HVCCC Attitude Questionnaire (MHAQ) was developed in four phases. First, we conducted exploratory factor analyses using original data from a previously published survey. Next, we added nine items to strengthen subscales and tested the new questionnaire among the four stakeholder groups. We used exploratory factor analysis and Cronbach’s alphas to define subscales, after which the final version of the MHAQ was constructed. Finally, we used generalizability theory to determine the number of respondents (residents or staff physicians) needed to reliably measure a specialty attitude score.ResultsInitial factor analysis identified three subscales. Thereafter, 301 residents, 297 staff physicians, 53 administrators and 792 patients completed the new questionnaire between June 2017 and July 2018. The best fitting subscale composition was a three-factor model. Subscales were defined as high-value care, cost incorporation, and perceived drawbacks. Cronbach’s alphas were between 0.61 and 0.82 for all stakeholders on all subscales. Sufficient reliability for assessing national specialty attitude (G-coefficient > 0.6) could be achieved from 14 respondents.ConclusionsThe MHAQ reliably measures individual attitudes toward HVCCC in different stakeholders in health care contexts. It addresses key dimensions of HVCCC, providing content validity evidence. The MHAQ can be used to identify frontrunners of HVCCC, pinpoint aspects of residency training that need improvement, and benchmark and compare across specialties, hospitals and regions.

High-Value, Cost-Conscious Communication Skills in Undergraduate Medical Education

Training in high-value, cost-conscious care (HVCCC) is increasingly being incorporated into medical school curricula, but students may have limited opportunities to engage patients in HVCCC conversations. The aim of this study was to develop two standardized patient scenarios with associated checklists, hypothesizing that resulting scores would allow for valid formative assessments of HVCCC communication skills. Scenarios were designed to generate a less-is-more conversation (in response to a patient requesting an unnecessary test) and a shared decision-making conversation (in response to a patient choosing between multiple effective treatment options). Checklists were developed by experts and informed by the existing literature. Validity evidence was collected from content, response process, internal structure, relations to other variables, and consequences of testing. Ninety-three third-year medical students participated during 2014-2015. Mean checklist scores were 79% (SD = 18, Cronbach α = 0.72) and 72% (SD = 13, Cronbach α = 0.62) for the less-is-more and shared decision-making scenarios, respectively. Checklist scores correlated with global ratings of performance (r = 0.65 and 0.54, respectively, both P < 0.001), and overall interrater reliability was good (r = 0.66). Checklist scores discriminated between higher and lower performers (discrimination indices of 0.84 and 0.65, respectively, both P < 0.001). Most students (83/90, 92%) agreed that the session improved their HVCCC communication skills. This study provides validity evidence supporting the use of scores derived from two standardized patient scenarios for formative assessment of HVCCC communication skills among third-year medical students. These scenarios can help equip students with practical, patient-centered strategies for promoting value in clinical encounters.

50 - Pediatric Chief Resident Perspective on High Value Cost Conscious Care Training during Residency: A National Survey

50 - Pediatric Chief Resident Perspective on High Value Cost Conscious Care Training during Residency: A National Survey

Pediatric Training Faculty and Resident Perceptions on Teaching High-Value, Cost-Conscious Care: A Multi-Institutional Study

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. 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. 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. 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.

Decreasing Unintended Medication Discrepancies in Medication Reconciliation through Simple Yet Effective Interventions

Background: Medication reconciliation is the process of comparing a patient's medication orders to all of the medications that the patient has been taking. Unfortunately, medication errors are common in our health system accounting for significant proportion of patient harm. The main objective of our study was to explore the effect of self-designed intervention in improving the accuracy of patient current medication list in the outpatient settings. Methods: The study designed entailed collection of data from October 2013 to March 2014. The data collected in October (The pre-intervention) was compared to the post-intervention data in March 2014. Following interventions were performed: Education of residents, nurses and patients, frequent reminders to the residents to perform medication reconciliation, sending notifications to the residents who failed to perform medication reconciliation, reminding the patients get all refills at the time of appointment and reminding the patients to bring pill bottles at each appointment. The pre-intervention data was compared with the post-intervention data for different types of medication errors. Normality of the variables was pre assessed. Non-parametric analysis using Fisher’s exact test was performed for comparison of categorical variables. Conclusion: In conclusion, our intervention improved the accuracy of patient current medication list in the electronic records as accurate as possible. For clinics and hospitals, medication reconciliation can enhance delivery of high value cost conscious care to the patients by reducing medication errors.

A Joint Quality Improvement and High-Value Care Curriculum in a Limited-Resource Setting

Since the release of the Institute of Medicine's To Err Is Human, there has been an increased focus on quality improvement (QI). QI training is now a requirement monitored via ACGME's clinical learning environment review committees. Given the significant cost of health care waste, teaching physicians to incorporate costs and value into medical decision making is crucial. Increasing information is available on methods to teach high-value care (HVC), but there is little information on combining HVC with QI. As these topics are intimately linked in efforts to provide effective, efficient care, a joint curriculum is a feasible solution. We adapted material from two online resources-(1) Institute of Healthcare Improvement Open School and (2) American College of Physicians High Value Cost-Conscious Care Curriculum-to create a combined curriculum for use in a limited-resource setting. Our curriculum is divided into 10 seminars, each including both QI techniques and HVC theories, which are reinforced using a series of patient scenarios. Residents apply their knowledge in self-directed projects presented in the final seminar. Evaluation includes a pre-/postexposure QI knowledge application test, survey of self-assessed knowledge, and anonymous course feedback. For the 46 residents who completed the series, a statistically significant improvement in both tests was measured, and feedback was positive overall. Tailoring our in-seminar patient scenarios allowed residents to demonstrate their HVC knowledge acquisition. This seminar-based curriculum can be adapted to the time availability in any residency program and transfer to other disciplines with modification of the patient scenarios.

Charting the Route to High-Value Care

Charting the Route to High-Value Care

The power of anecdotes on resident HVCCC curriculum

A formal high value, cost-conscious care (HVCCC) curriculum was implemented at a community hospital-based university-affiliated residency program starting January 1, 2014, based on the recommendations of the American Board of Internal Medicine's (ABIM) Choosing Wisely campaign. The program included a competition requiring each resident to write a HVCCC case based on an actual patient experience. Residents completed a questionnaire assessing their understanding of HVCCC near the end of the program. Residents subsequently reviewed two actual cases that had vividly described unexpected adverse outcomes (‘anecdotal’ cases). Postexposure data were collected and the results were analyzed.