Physician Stewardship Research Articles

Toward High-Value, Cost-Conscious Care – Supporting Future Doctors to Adopt a Role as Stewards of a Sustainable Healthcare System

Phenomenon: In order to tackle the persistent rise of healthcare costs, physicians as “stewards of scarce resources” could be effective change agents, extending cost containment efforts from national policy to the micro level. Current programs focus on educating future doctors to deliver “high-value, cost-conscious care” (HVCCC). Although the importance of HVCCC education is increasingly recognized, there is a lag in implementation. Whereas recent efforts generated effective interventions that promote HVCCC in a local context, gaps persist in the examination of system factors that underlie broader successful and lasting implementation in educational and healthcare practices. Approach: We conducted a realist evaluation of a program focused on embedding HVCCC in postgraduate education by encouraging and supporting residents to set up “HVCCC projects” to promote HVCCC delivery. We interviewed 39 medical residents and 10 attending physicians involved in such HVCCC projects to examine HVCCC implementation in different educational and healthcare contexts. We held six reflection sessions attended by the program commissioners and educationalists to validate and enrich the findings. Findings: A realist evaluation was used to unravel the facilitators and barriers that underlie the implementation of HVCCC in a variety of healthcare practices. Whereas research activities regularly stop after the identification of facilitators and barriers, we used these insights to formulate four high-value, cost-conscious care carriers: (1) continue to promote HVCCC awareness, (2) create an institutional structure that fosters HVCCC, (3) continue the focus on projects for embedding HVCCC in practice, (4) generate evidence. The carriers support residents, attendings and others involved in educating physicians in training to develop and implement innovative HVCCC projects. Insights: Strategies to promote physician stewardship go beyond the formal curriculum and require a transformation in the informal educational system from one that almost exclusively focuses on medical discussions to one that also considers value and cost as part of medical decision-making. The HVCCC carriers propose a set of strategies and system adaptations that could aid the transformation toward a HVCCC supporting context.

220. Taking Off With Antimicrobial Intervention Rounds (AIR): Successes of a Pilot Stewardship Service at a Tertiary-Care VA Medical Center

BackgroundProspective audit and feedback is one of the core strategies of an antimicrobial stewardship program (ASP). Here, we hypothesized that the addition of AIR to our extant ASP would enhance appropriate use of parenteral (IV) antibiotics (ABs) on a large inpatient medical service.MethodsAdult patients on medicine wards beginning in October 2017 and not followed by the infectious diseases (ID) service were included for stewardship intervention if they were on IV ABs ≥48 hours. Recommendations were classified into: (1) duration of therapy; (2) dose adjustment; (3) IV to oral conversion; (4) adverse event prevention; (5) AB avoidance; (6) anti-pseudomonal or (7) vancomycin de-escalation; (8) AB discontinuation; (9) ID consult; (10) Δ alternative AB; (11) allergy assessment; or (12) diagnostics. Early impact of the interventions was assessed after 3 months via the Standardized Antimicrobial Administration Ratio (SAAR) and compared with the 3-month, pre-AIR period. The SAAR is used to benchmark facilities’ AB use against those of similar complexity; SAAR = 1 indicates that observed = predicted use.ResultsFor 158 interventions made, the most common syndromes were pneumonia (41%), skin and soft tissue (29.4%), and urinary tract infection (17.7%). Intervention categories other than 4, 9, and 11 had acceptance rates >85% (Figure 1). The SAAR decreased from the pre- to post-AIR period in terms of agents for: broad-spectrum use in HAI (SAAR relative ratio [RR]: 0.80, 95% CI [0.73–0.88]); MRSA (SAAR RR: 0.81, 95% CI [0.73–0.91]); and all indications (SAAR RR: 0.86, 95% CI [0.82–0.90]). During the same periods, surgical wards without AIR showed no Δ in AB use.ConclusionThe majority of AB use recommendations delivered by a pharmacist–physician stewardship team were highly accepted by medical providers and led to a 15–20% decrease in overall AB use, without adverse effect during the immediate postintervention period. Potential clinical benefits, such as decreased rates of Clostridium difficile disease, will need to be measured as the AIR program advances. It is worth noting that interventions for AB allergy assessment were least accepted by providers, possibly due to time required to comply. Design of prospective audit and feedback programs may need to address this potential deficiency. Disclosures All authors: No reported disclosures.

Post-operative Weaning of Opioids After Ambulatory Surgery: the Importance of Physician Stewardship.

We performed a systematic review to elucidate the current guidelines on weaning patients from opioids in the post-operative ambulatory surgery setting, and how pain management intraoperatively can impact this process. The review highlights the most up-to-date research from clinical trials, patient reports, and retrospective studies regarding both the current guidelines and weaning of opioid analgesia in ambulatory surgery setting. A striking paucity of convincing evidence exists on ambulatory postoperative pain management discontinuation or weaning of pain medications. However, retrospective and patient-reported studies suggest our approach should be similar to acute pain management strategies. The first steps include identifying high-risk patients and devising an appropriate pain plan. This may be accomplished by implementing multimodal analgesia, anticipating opioid needs, and the proper use of regional anesthesia. The increasing roles for Transitional Pain Service (TPS), Perioperative Surgical Home (PSH), and Enhanced Recovery After Surgery (ERAS) may also guide us in this process. Patients discharged from same-day surgery may lack the additional infrastructure of a hospital or medical establishment to monitor postoperative recovery. As such, weaning of pain medications in ambulatory surgery settings requires teams that are adept at treating varied patient populations through a tailored, novel means that invoke multimodal analgesia. Given the growth of surgeries moving toward the ambulatory sector, more data and practice guidelines are needed to direct postoperative pain regimen titration for the patients.

Patterns of Narcotic Prescribing by Orthopedic Surgeons for Medicare Patients.

In recent years, narcotics have been subject to increased regulation and monitoring because of their side effects and potential for misuse. Currently, variation in prescribing patterns of narcotics among orthopedic surgeons is unknown. The Medicare Part D claims database was used to identify orthopedic surgeons who prescribed at least one schedule II or III narcotic during 2014. The median duration of a narcotic prescription was 8.2 days. The median prescription duration was shortest for hand surgeons (5.6 days) and longest for spine surgeons (12.6 days). Orthopedic surgeons in New York (10.1 days) provided the most narcotics per prescription, with physicians in Vermont (6.2 days) providing the least. Substantial variation exists in narcotic prescribing patterns for orthopedic surgeons at the individual, subspecialty, and statewide levels. With public health focus on reducing narcotics abuse, physician stewardship of these medications will become increasingly relevant.

Stewardship of primary care physicians to contain cost in health care: an international cross-sectional survey.

Physician stewardship towards cost control is potentially important in enhancing the financial sustainability of health care systems. 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. 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. 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. 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.

AMA Code of Medical Ethics Gets Long-Awaited Update

AMA <i>Code of Medical Ethics</i> Gets Long-Awaited Update

Exit Survey of Senior Residents: Cost Conscious but Uninformed.

Background Cost awareness, to ensure physician stewardship of limited resources, is increasingly recognized as an important skill for physicians. The Accreditation Council for Graduate Medical Education has made cost awareness part of systems-based practice, a core competency of resident education. However, little is known about resident cost awareness. Objective We sought to assess senior resident self-perceived cost awareness and cost knowledge. Methods In March 2014, we conducted a cross-sectional survey of all emergency medicine, internal medicine, obstetrics and gynecology, orthopaedic surgery pediatrics, and medicine-pediatrics residents in their final year at Yale-New Haven Hospital. The survey examined attitudes toward health care costs and residents' estimates of order prices. We considered resident price estimates to be accurate if they were between 50% and 200% of the Connecticut-specific Medicare price. Results We sent the survey to 84 residents and received 47 completed surveys (56% response rate). Although more than 95% (45 of 47) felt that containing costs is the responsibility of every clinician, and 49% (23 of 47) agreed that cost influenced their decision when ordering, only 4% (2 of 47) agreed that they knew the cost of tests being ordered. No residents accurately estimated the price of a complete blood count with differential, and only 2.1% (1 of 47) were accurate for a basic metabolic panel. The overall accuracy of all resident responses was 25%. Conclusions In our study, many trainees exit residency with self-identified deficiencies in knowledge about costs. The findings show the need for educational approaches to improve cost awareness among trainees.

AMA Code of Medical Ethics' Opinion on Physician Stewardship

Opinion 9.0652 - Physician Stewardship of Health Care Resources Physicians’ primary ethical obligation is to promote the well-being of individual patients. Physicians also have a long-recognized obligation to patients in general to promote public health and access to care. This obligation requires physicians to be prudent stewards of the shared societal resources with which they are entrusted. Managing health care resources responsibly for the benefit of all patients is compatible with physicians’ primary obligation to serve the interests of individual patients.

Physician Stewardship of Health Care in an Era of Finite Resources

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