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Cheng MKW, Telleria-Cano JM, Nath JB, Rieger EY, Rhee A, Tang JW, Yang CW. Imaging Wisely: An Introduction to the ACR Appropriateness Criteria® and Analysis of Its Impact on Internal Medicine Trainees. J Am Coll Radiol 2023; 20:1059-1062. [PMID: 37331572 DOI: 10.1016/j.jacr.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 04/10/2023] [Accepted: 04/14/2023] [Indexed: 06/20/2023]
Affiliation(s)
- Mike K W Cheng
- Division of General Internal Medicine, University of California San Francisco, San Francisco, California. https://twitter.com/mikekwcheng
| | | | - Julia B Nath
- Department of Internal Medicine, California Pacific Medical Center, San Francisco, California. https://twitter.com/JuliaBNath
| | - Erin Y Rieger
- Department of Internal Medicine, Columbia University Irving Medical Center, New York, New York. https://twitter.com/erinyrieger
| | - Annie Rhee
- Department of Radiology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Joyce W Tang
- Department of Medicine, University of Chicago, Chicago, Illinois. https://twitter.com/joycewtang
| | - Carina W Yang
- Pediatric Neuroradiology, Department of Radiology; Faculty Director of Fellowship Accreditation, Graduate Medical Education, University of Chicago, Chicago, Illinois.
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Tan E, Ng WM, Soh PC, Tan D, Cleland J. 'But what if you miss something …?': factors that influence medical student consideration of cost in decision making. BMC MEDICAL EDUCATION 2023; 23:437. [PMID: 37316844 DOI: 10.1186/s12909-023-04349-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 05/11/2023] [Indexed: 06/16/2023]
Abstract
CONTEXT Cost-conscious care is critical for healthcare sustainability but evidence suggests that most doctors do not consider cost in their clinical decision making. A critical step in changing this is understanding the barriers to encouraging behaviours and attitudes related to cost-conscious care. We therefore conducted a qualitative study to address the research question: what factors influence consideration of cost in emergency medicine (ED) clinical decision making? METHODS This was a qualitative focus group study using patient vignettes to explore attitudes towards cost-conscious clinical decision making. Participants were Year 4 and Year 5 medical students from Singapore, a country with a fee-for-service healthcare system. After a data-driven initial data analysis, and to make sense of a multitude of factors impacting on cost conscious care, we selected Fishbein's integrative model of behavioural prediction to underpin secondary data analysis. RESULTS Via four focus groups with 21 participants, we identified five main themes relevant to the integrative model of behavioural prediction. These were: attitudes towards considering cost when managing a patient (e.g., "better safe than sorry"); normative beliefs (e.g., doing what others do, perceptions of patient wishes); efficacy beliefs (e.g., no authority to take decisions or challenge); skills and knowledge (e.g., little knowledge of costs), and environmental constraints (e.g., the nature of the healthcare system). DISCUSSION Medical students do not consider cost in their clinical decision making due to numerous factors, of which lack of knowledge of costs is but one. While some of the factors identified reflect those found in previous studies with residents and fully-trained staff, and in other contexts, theory driven analysis added value in that it facilitated a richer exploration of why students do not consider cost in clinical decision making. Our findings provide insight to inform how best to engage and empower educators and learners in teaching and learning about cost-conscious care.
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Affiliation(s)
- Emmanuel Tan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.
| | - Wei Ming Ng
- Department of Emergency Medicine, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Poh Choong Soh
- Department of Emergency Medicine, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Daniel Tan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Jennifer Cleland
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
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van Engen V, Bonfrer I, Ahaus K, Buljac-Samardzic M. Value-Based Healthcare From the Perspective of the Healthcare Professional: A Systematic Literature Review. Front Public Health 2022; 9:800702. [PMID: 35096748 PMCID: PMC8792751 DOI: 10.3389/fpubh.2021.800702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 12/21/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Quality improvement education in surgical specialty training: A comparison of Vascular Surgery resident and Urology Resident experiences and attitudes. Am J Surg 2020; 221:993-999. [PMID: 33032790 DOI: 10.1016/j.amjsurg.2020.09.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 09/26/2020] [Accepted: 09/28/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Academic institutions have increasingly focused on educating physicians and surgeons in concepts of value-based care, including quality improvement (QI). The extent to which QI curricular competencies are addressed in specialty surgical residency training is unclear. METHODS A survey instrument was developed by content experts and sent to Vascular Surgery and Urology residents electronically. Descriptive statistics and bivariate associations were calculated using StataMP 13.1. RESULTS Vascular Surgery and Urology residents reported exposure to similar types of QI curriculum. Fewer than half of residents reported achieving targets for graduation (Vascular 31%, Urology 42%) related to QI, and few residents in either group felt very well-prepared to lead a QI initiative (Vascular 13%, Urology 8%). CONCLUSION QI education in surgical specialty training amongst Vascular Surgery and Urology residencies is similar and insufficient. Surgical specialties may benefit from collaborative efforts to improve the quality of QI education.
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Malhotra NR, Smith JD, Jacobs AC, Johnson CE, Khan US, Ellison HB, Brintz BJ, Millar MM, Cloud WG, Nahmias J, Hendershot KM, Smith BK. High value care education in general surgery residency programs: A multi-institutional needs assessment. Am J Surg 2020; 221:291-297. [PMID: 33039148 DOI: 10.1016/j.amjsurg.2020.09.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/22/2020] [Accepted: 09/08/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The ACGME mandates that residency programs provide training related to high value care (HVC). The purpose of this study was to explore HVC education in general surgery residency programs. METHODS An electronic survey was distributed to general surgery residents in geographically diverse programs. RESULTS The response rate was 29% (181/619). Residents reported various HVC components in their curricula. Less than half felt HVC is very important for their future practice (44%) and only 15% felt confident they could lead a QI initiative in practice. Only 20% of residents reported participating in a root cause analysis and less than one-third of residents (30%) were frequently exposed to cost considerations. CONCLUSION Few residents feel prepared to lead quality improvement initiatives, have participated in patient safety processes, or are aware of patients' costs of care. This underscores the need for improved scope and quality of HVC education and establishment of formal curricula.
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Affiliation(s)
- Neha R Malhotra
- University of Utah, Department of Surgery, Division of Urology, United States.
| | | | | | - Cali E Johnson
- University of Southern California, Department of Surgery, Division of Vascular Surgery, United States.
| | - Uzer S Khan
- West Virginia University, Department of Surgery, United States.
| | - Halle B Ellison
- Geisinger Health, Department of Surgery, Department of Palliative Care, United States.
| | - Benjamin J Brintz
- University of Utah, Department of Internal Medicine, Division of Epidemiology, United States.
| | - Morgan M Millar
- University of Utah, Department of Internal Medicine, Division of Epidemiology, United States.
| | - William G Cloud
- Baptist Memorial Memphis, Department of Surgery, Chief Quality & Safety Officer, United States.
| | - Jeffry Nahmias
- University of California - Irvine, Department of Surgery, United States.
| | | | - Brigitte K Smith
- University of Utah, Department of Surgery, Division of Vascular Surgery, Vice-Chair of Education, United States.
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Tseng EK, Mukerji G, Weinerman A, Fuller J, McLeod A, Wong BM, Kuper A, Stroud LS. Choosing Words Wisely: Residents' Use of Rhetorical Appeals in Conversations About Unnecessary Tests. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2020; 95:275-282. [PMID: 31517680 DOI: 10.1097/acm.0000000000002980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE To characterize how residents employ rhetorical appeals (i.e., the strategic use of communication to achieve specifiable goals) when discussing unnecessary diagnostic tests with patients. METHOD In 2015, senior hematology residents from 10 Canadian universities participating in a national formative objective structured clinical examination (OSCE) completed a resource stewardship communication station. In this communication scenario, a standardized patient (SP) portrayed a patient requesting unnecessary thrombophilia testing following early pregnancy loss. The authors performed a thematic analysis of audio transcripts using a qualitative description approach to identify residents' rhetorical appeals to logic (rational appeals), credibility, and emotion. RESULTS For persuasive communication, residents (n = 27) relied primarily on rational appeals that fit into 3 categories (with themes) focused on medical evidence (poor utility, professional guidelines and recommendations), avoidance of harm (insurance implications, unnecessary or potentially harmful interventions, patient anxiety), and reassurance to patient (normalizing, clinical pretest probability, criteria for reconsidering testing). Appeals to credibility and emotion were rarely used. CONCLUSIONS In an OSCE setting, residents relied predominantly on rational appeals when engaging SPs in conversations about unnecessary tests. These observations yield insights into how recent emphasis within residency education on appropriate test utilization may manifest when residents put recommendations into practice in conversations with patients. This study's framework of rational appeals may be helpful in designing communication curricula about unnecessary testing. Future studies should explore rhetoric about unnecessary testing in the clinical environment, strategies to teach and coach residents leading these conversations, and patients' preferences and responses to different appeals.
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Affiliation(s)
- Eric K Tseng
- E.K. Tseng is assistant professor, Department of Medicine, University of Toronto, and staff physician, Division of Hematology/Oncology, St. Michael's Hospital, Toronto, Ontario, Canada. G. Mukerji is assistant professor, Department of Medicine, University of Toronto, and staff physician, Division of Endocrinology, Women's College Hospital, Toronto, Ontario, Canada. A. Weinerman is assistant professor, Department of Medicine, University of Toronto, and staff physician, Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. J. Fuller is assistant professor, Department of History and Philosophy of Science, University of Pittsburgh, Pittsburgh, Pennsylvania, and research associate, African Centre for Epistemology and Philosophy of Science, University of Johannesburg, Johannesburg, South Africa. A. McLeod is assistant professor, Department of Medicine, University of Toronto, and staff physician, Division of Hematology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. B.M. Wong is associate professor, Department of Medicine, and associate director, Centre for Quality Improvement and Patient Safety, University of Toronto, and staff physician, Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. A. Kuper is associate professor, Department of Medicine, and education scientist, Wilson Centre for Education, University of Toronto, and staff physician, Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. L.S. Stroud is associate professor, Department of Medicine, and centre researcher, Wilson Centre for Education, University of Toronto, and staff physician, Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Stammen L, Slootweg I, Stalmeijer R, Janssen L, Stassen L, Scheele F, Driessen E. The Struggle Is Real: How Residents Learn to Provide High-Value, Cost-Conscious Care. TEACHING AND LEARNING IN MEDICINE 2019; 31:402-411. [PMID: 30909747 DOI: 10.1080/10401334.2019.1583566] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Phenomenon: Rising healthcare expenditures threaten the accessibility and affordability of healthcare systems. Research has demonstrated that teaching (junior) physicians to deliver high-value, cost-conscious care can be effective when learning is situated in a supportive environment. This study aims to offer insight into how residents learn to provide high-value, cost-conscious care in the workplace and how the postgraduate training environment influences this learning. Approach: Six homogeneous focus groups were held between August 2015 and July 2016 with 36 residents from six residency programs (dermatology, n = 5; elderly care, n = 8; family medicine, n = 5; internal medicine, n = 6; orthopedic surgery, n = 6; surgery, n = 6). An iterative grounded theory approach was used to analyze the qualitative data. Findings: Influential factors in learning of high-value, cost-conscious care delivery operated on three levels: individual resident, training program, and the workplace. On the individual level, we discerned three types of beliefs regarding HV3C. At the training program level, perceived determinants of learning included resident-supervisor interactions, involvement in decision-making over time, and exposure to variation in care delivery. At the workplace level, learning depended on the availability of professional healthcare expertise and the presence of institutional policy. Insights: Residents struggle to seize high-value, cost-conscious care learning opportunities in the workplace setting. Both residency training programs and workplaces can contribute to creating these learning opportunities. An important starting point is being aware of the different personal beliefs of residents and the approaches to high-value, cost-conscious care on the level of the training program and workplace.
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Affiliation(s)
- Lorette Stammen
- a School of Health Professions Education (SHE), Department of Educational Research and Development, Maastricht University , Maastricht , Limburg , The Netherlands
| | - Irene Slootweg
- b Department of Public Health and Primary Care, Leiden University Medical Centre , Leiden , The Netherlands
| | - Renée Stalmeijer
- a School of Health Professions Education (SHE), Department of Educational Research and Development, Maastricht University , Maastricht , Limburg , The Netherlands
| | - Linda Janssen
- a School of Health Professions Education (SHE), Department of Educational Research and Development, Maastricht University , Maastricht , Limburg , The Netherlands
| | - Laurents Stassen
- c Department of Surgery, Maastricht University Medical Center , Maastricht , The Netherlands
| | - Fedde Scheele
- d VU School of Medical Sciences, Amsterdam UMC, Athena Institute , Amsterdam , The Netherlands
- e OLVG Amsterdam , Amsterdam , The Netherlands
| | - Erik Driessen
- a School of Health Professions Education (SHE), Department of Educational Research and Development, Maastricht University , Maastricht , Limburg , The Netherlands
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Schickedanz A, Gupta R, Arora VM, Braddock CH. Measuring Value in Internal Medicine Residency Training Hospitals Using Publicly Reported Measures. Am J Med Qual 2018; 33:604-613. [PMID: 29637791 PMCID: PMC6697657 DOI: 10.1177/1062860618767312] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Graduate medical education (GME) lacks measures of resident preparation for high-quality, cost-conscious practice. The authors used publicly reported teaching hospital value measures to compare internal medicine residency programs on high-value care training and to validate these measures against program director perceptions of value. Program-level value training scores were constructed using Centers for Medicare & Medicaid Services Value-Based Purchasing (VBP) Program hospital quality and cost-efficiency data. Correlations with Association of Program Directors in Internal Medicine Annual Survey high-value care training measures were examined using logistic regression. For every point increase in program-level VBP score, residency directors were more likely to agree that GME programs have a responsibility to contain health care costs (adjusted odds ratio [aOR] 1.18, P = .04), their faculty model high-value care (aOR 1.07, P = .03), and residents are prepared to make high-value medical decisions (aOR 1.07, P = .09). Publicly reported clinical data offer valid measures of GME value training.
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Affiliation(s)
- Adam Schickedanz
- Primary Care & Health Services Research Fellow, Department of Pediatrics, University of California Los Angeles, Los Angeles, CA
| | - Reshma Gupta
- Medical Director for Quality Improvement & Value at UCLA Health, Department of Medicine, University of California Los Angeles, Los Angeles, CA
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