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

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

BACKGROUND

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.

OBJECTIVE

To explore the relationship between medical student experiences and HVCCC attitudes.

DESIGN

Quantitative and qualitative analysis of a multi-institutional survey.

PARTICIPANTS

Medical students from nine US medical schools.

APPROACH

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.

KEY RESULTS

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.

CONCLUSION

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.

Novel use of an OSCE to assess medical students' responses to a request for a low value diagnostic imaging test: A mixed methods analysis

OBJECTIVE

Evaluate medical students' communication skills with a standardized patient (SP) requesting a low value test and describe challenges students identify in addressing the request.

METHODS

In this mixed-methods study, third-year students from two medical schools obtained a history, performed a physical examination, and counseled an SP presenting with uncomplicated low back pain who requests an MRI which is not indicated. SP raters evaluated student communication skills using a 14-item checklist. Post-encounter, students reported whether they ordered an MRI and challenges faced.

RESULTS

Students who discussed practice guidelines and risks of unnecessary testing with the SP were less likely to order an MRI. Students cited several challenges in responding to the SP request including patient characteristics and circumstances, lack of knowledge about MRI indications and alternatives, and lack of communication skills to address the patient request.

CONCLUSIONS

Most students did not order an MRI for uncomplicated LBP, but only a small number of students educated the patient about the evidence to avoid unnecessary imaging or the harm of unnecessary testing.

PRACTICE IMPLICATIONS

Knowledge about unnecessary imaging in uncomplicated LBP may be insufficient to adhere to best practices and longitudinal training in challenging conversations is needed.

Physician and Hospital-level Variation in Hemostatic Agent Use in Benign Gynecologic Procedures

STUDY OBJECTIVE

To identify recent nationwide trends in hemostatic agent (HA) use and to explore factors associated with HA use in 3 benign gynecologic surgery contexts: isolated hysterectomy, pelvic organ prolapse repair, and anti-incontinence surgery.

DESIGN

Retrospective cohort study.

SETTING

Vizient Clinical Database.

PATIENTS

Three cohorts of female patients of ≥18 years who underwent benign isolated hysterectomy, pelvic organ prolapse repair, or anti-incontinence procedures were identified between October 2015 and December 2019.

INTERVENTIONS

HAs are topically applied procoagulant products used for surgical hemostasis and use during included encounters was determined by charge codes.

MEASUREMENTS AND MAIN RESULTS

Subject-, hospital-, and surgeon-level characteristics and costs were captured. Data were initially analyzed in the aggregate and based on procedure category using the chi-square test or independent samples t tests as appropriate. A bootstrap forest model was used to identify the factors most predictive of HA use. In the final cohort of 184 070 encounters, HAs were used most frequently in hysterectomy (20.7%) and least in anti-incontinence surgery (10.9%). The use of HAs increased from 15.6% in quarter 4 2015 to 19.2% in quarter 4 2019 (p <.001). Encounters using HAs cost more than encounters without HAs ($6271.10 vs $4572.00; p <.001). A bootstrap forest model inclusive of all variables found surgeon and hospital identity cumulatively predictive of 84.9% of HA use, 65.5% and 19.4%, respectively. There was significant variation in HA use among individual surgeons, with 59.9% never using HAs. Of those who did use HAs, 72.8% used HAs more frequently than the mean provider HA use rate (19.4%) and 9.2% used HAs in every case he/she performed.

CONCLUSION

The significant variation in HA use is driven primarily by physician and hospital identity, suggesting that use of HA in these benign gynecologic surgical contexts may be determined more by physician- and hospital-level factors than patient-level factors.

Pediatric Residents' Experiences With High-Value Care at an Academic Children's Hospital

BACKGROUND

The Accreditation Council for Graduate Medical Education mandates residents incorporate cost considerations into patient care. However, resident experiences with high-value care (HVC) in the clinical setting have not been well described.

OBJECTIVE

To explore pediatric residents' experiences with HVC and its facilitators and barriers.

METHODS

We performed a qualitative study with a grounded theory epistemology of pediatric residents recruited by email at a large academic children's hospital. We conducted focus groups (n=3) and interviews (n=7) between February and September 2020 using a semi-structured guide. Data were analyzed using the constant comparative method. Codes were built using an iterative approach and organized into thematic categories. Sampling continued until saturation was reached.

RESULTS

Twenty-two residents participated. Residents' value-based health care decisions occurred in a complex learning environment. Due to limited experience, residents feared missing diagnoses, which contributed to perceived overtesting. Resident autonomy, with valuable experiential learning, supported and hindered HVC. Informal teaching occurred through patient care discussions; however, cost information was lacking. Practice of HVC varied by clinical setting with greater challenges on high acuity and subspecialty services. For children with medical complexity, identifying family concerns and goals of care improved value. Family experience/demands influenced resident health care decisions, contributing to high- and low-value care. Effective collaboration among health care team members was crucial; residents often felt pressured following perceived low-value recommendations from consultants.

CONCLUSIONS

Resident HVC learning and practice is influenced by multiple factors in a complex clinical learning environment.

Value-Based Healthcare From the Perspective of the Healthcare Professional: A Systematic Literature Review

Introduction: Healthcare systems increasingly move toward “value-based healthcare” (VBHC), aiming to further improve quality and performance of care as well as the sustainable use of resources. Evidence about healthcare professionals' contributions to VBHC, experienced job demands and resources as well as employee well-being in VBHC is scattered. This systematic review synthesizes this evidence by exploring how VBHC relates to the healthcare professional, and vice versa.

Method: Seven databases were systematically searched for relevant studies. The search yielded 3,782 records, of which 45 were eligible for inclusion based on a two-step screening process using exclusion criteria performed by two authors independently. The quality of the included studies was appraised using the Mixed Methods Appraisal Tool (MMAT). Based on inductive thematic analysis, the Job Demands-Resources (JD-R) model was modified. Subsequently, this modified model was applied deductively for a second round of thematic analysis.

Results: Ten behaviors of healthcare professionals to enhance value in care were identified. These behaviors and associated changes in professionals' work content and work environment impacted the experienced job demands and resources and, in turn, employee well-being and job strain. This review revealed 16 constructs as job demand and/or job resource. Examples of these include role strain, workload and meaning in work. Four constructs related to employee well-being, including engagement and job satisfaction, and five constructs related to job strain, including exhaustion and concerns, were identified. A distinction was made between job demands and resources that were a pure characteristic of VBHC, and job demands and resources that resulted from environmental factors such as how care organizations shaped VBHC.

Conclusion and Discussion: This review shows that professionals experience substantial job demands and resources resulting from the move toward VBHC and their active role therein. Several job demands are triggered by an unsupportive organizational environment. Hence, increased organizational support may contribute to mitigating or avoiding adverse psychosocial factors and enhance positive psychosocial factors in a VBHC context. Further research to estimate the effects of VBHC on healthcare professionals is warranted.