The Struggle Is Real: How Residents Learn to Provide High-Value, Cost-Conscious Care

Pediatric Residency Training amid the COVID-19 Pandemic: Exploring the Impact of Supervision and Clinical Practice Guidelines on Clinical and Financial Outcomes

Objective

This study is aimed at calculating the magnitude of the effect of clinical practice guidelines (CPG) and supervision in inhibiting the negative impact of the COVID-19 pandemic on clinical and financial outcomes of non-COVID-19 inpatient care by pediatric residents in academic medical center (AMC) hospitals during the COVID-19 pandemic.

Methods

The cohort retrospective study was conducted. This study collected patient data from pediatric residency programs. A research cohort consisted of non-COVID-19 pediatric patients at Dr. Soetomo General Academic Hospital. This study compared the subgroup of patients treated during the pandemic with those treated before the pandemic. The results were analyzed using SPSS 26.0 and Smart-PLS.

Results

There was a 41.4% decrease in pediatric inpatients during the pandemic with an increased severity level and complexity level, a reduction of 7.46% availability of supervisors, an increase of 0.4% in readmission < 30 days, an increase of 0.31% in-hospital mortality, an increase the total costs of care, and a decrease of insurance claim profit. CPG did not moderate the effect of the COVID-19 pandemic on the clinical outcomes (β = −0.006, P = 0.083) but moderated the financial outcomes (β = −0.022, P = 0.000), by reducing the total cost of care and increasing insurance claim profit. Supervision moderated the effect of the COVID-19 pandemic on the clinical outcomes (β = 0.040, P = 0.000) by increasing aLOS and on the financial outcomes (β = −0.031, P = 0.000) by reducing the total cost of care and increasing insurance claim profit. This study model had a 24.0% variance of explanatory power for clinical outcomes and 49.0% for financial outcomes. This study's structural model effectively predicted clinical outcomes (Q² = 0.238) and financial outcomes (Q² = 0.413).

Conclusion

Direct supervision inhibited the negative impact of the COVID-19 pandemic on both clinical and financial outcomes of non-COVID-19 inpatient care by pediatric residents, while CPG only inhibited the negative impact on financial outcomes. Implication of This Study. In a disaster, the availability of CPG and direct supervision makes AMC hospitals able to inhibit the negative impact of disasters on clinical and financial outcomes.

Incorporating value-based healthcare projects in residency training: a mixed-methods study on the impact of participation on understanding and competency development

OBJECTIVES

Stimulating the active participation of residents in projects with societally relevant healthcare themes, such as value-based healthcare (VBHC), can be a strategy to enhance competency development. Canadian Medical Education Directions for Specialists (CanMEDS) competencies such as leader and scholar are important skills for all doctors. In this study, we hypothesise that when residents conduct a VBHC project, CanMEDS competencies are developed. There is the added value of gaining knowledge about VBHC.

DESIGN

An explorative mixed-methods study assessing residents' self-perceived learning effects of conducting VBHC projects according to three main components: (1) CanMEDS competency development, (2) recognition of VBHC dilemmas in clinical practice, and (3) potential facilitators for and barriers to implementing a VBHC project. We triangulated data resulting from qualitative analyses of: (a) text-based summaries of VBHC projects by residents and (b) semistructured interviews with residents who conducted these projects.

SETTING

Academic and non-academic hospitals in the Netherlands.

PARTICIPANTS

Out of 63 text-based summaries from residents, 56 were selected; and out of 19 eligible residents, 11 were selected for semistructured interviews and were included in the final analysis.

RESULTS

Regarding CanMEDS competency development, the competencies 'leader', 'communicator' and 'collaborator' scored the highest. Opportunities to recognise VBHC dilemmas in practice were mainly stimulated by analysing healthcare practices from different perspectives, and by learning how to define costs and relate them to outcomes. Finally, implementation of VBHC projects is facilitated by a thorough investigation of a VBHC dilemma combined with an in-depth stakeholder analysis.

CONCLUSION

In medical residency training programmes, competency development through active participation in projects with societally relevant healthcare themes-such as VBHC-was found to be a promising strategy. From a resident's perspective, combining a thorough investigation of the VBHC dilemma with an in-depth stakeholder analysis is key to the successful implementation of a VBHC project.

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.

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.

Reporting standards, outcomes and costs of quality improvement studies in Ireland: a scoping review

OBJECTIVES

To profile the aims and characteristics of quality improvement (QI) initiatives conducted in Ireland, to review the quality of their reporting and to assess outcomes and costs.

DESIGN

Scoping review.

DATA SOURCES

Systematic searches were conducted in PubMed, Web of Science, Embase, Google Scholar, Lenus and rian.ie. Two researchers independently screened abstracts (n=379) and separately reviewed 43 studies identified for inclusion using a 70-item critique tool. The tool was based on the Quality Improvement Minimum Quality Criteria Set (QI-MQCS), an appraisal instrument for QI intervention publications, and health economics reporting criteria. After reaching consensus, the final dataset was analysed using descriptive statistics. To support interpretations, findings were presented at a national stakeholder workshop.

ELIGIBILITY CRITERIA

QI studies implemented and evaluated in Ireland and published between January 2015 and April 2020.

RESULTS

The 43 studies represented various QI interventions. Most studies were peer-reviewed publications (n=37), conducted in hospitals (n=38). Studies mainly aimed to improve the 'effectiveness' (65%), 'efficiency' (53%), 'timeliness' (47%) and 'safety' (44%) of care. Fewer aimed to improve 'patient-centredness' (30%), 'value for money' (23%) or 'staff well-being' (9%). No study aimed to increase 'equity'. Seventy per cent of studies described 14 of 16 QI-MQCS dimensions. Least often studies reported the 'penetration/reach' of an initiative and only 35% reported health outcomes. While 53% of studies expressed awareness of costs, only eight provided at least one quantifiable figure for costs or savings. No studies assessed the cost-effectiveness of the QI.

CONCLUSION

Irish QI studies included in our review demonstrate varied aims and high reporting standards. Strategies are needed to support greater stimulation and dissemination of QI beyond the hospital sector and awareness of equity issues as QI work. Systematic measurement and reporting of costs and outcomes can be facilitated by integrating principles of health economics in QI education and guidelines.

Reducing Inappropriate Proton Pump Inhibitors Use for Stress Ulcer Prophylaxis in Hospitalized Patients: Systematic Review of De-Implementation Studies

BACKGROUND

A large proportion of proton pump inhibitor (PPI) prescriptions, including those for stress ulcer prophylaxis (SUP), are inappropriate. Our study purpose was to systematically review the effectiveness of de-implementation strategies aimed at reducing inappropriate PPI use for SUP in hospitalized, non-intensive care unit (non-ICU) patients.

METHODS

We searched MEDLINE and Embase databases (from inception to January 2020). Two authors independently screened references, performed data extraction, and critical appraisal. Randomized trials and comparative observational studies were eligible for inclusion. Criteria developed by the Cochrane Effective Practice and Organisation of Care (EPOC) group were used for critical appraisal. Besides the primary outcome (inappropriate PPI prescription or use), secondary outcomes included (adverse) pharmaceutical effects and healthcare use.

RESULTS

We included ten studies in this review. Most de-implementation strategies contained an educational component (meetings and/or materials), combined with either clinical guideline implementation (n = 5), audit feedback (n = 3), organizational culture (n = 4), or reminders (n = 1). One study evaluating the de-implementation strategy effectiveness showed a significant reduction (RR 0.14; 95% CI 0.03-0.55) of new inappropriate PPI prescriptions. Out of five studies evaluating the effectiveness of de-implementing inappropriate PPI use, four found a significant reduction (RR 0.21; 95% CI 0.18-0.26 to RR 0.76; 95% CI 0.68-0.86). No significant differences in the occurrence of pharmaceutical effects (n = 1) and in length of stay (n = 3) were observed. Adverse pharmaceutical effects were reported in two studies and five studies reported on PPI or total drug costs. No pooled effect estimates were calculated because of large statistical heterogeneity between studies.

DISCUSSION

All identified studies reported mainly educational interventions in combination with one or multiple other intervention strategies and all interventions were targeted at providers. Most studies found a small to moderate reduction of (inappropriate) PPI prescriptions or use.

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

BACKGROUND

Training 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.

OBJECTIVE

We 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.

DESIGN

We conducted a cross-sectional survey across the Netherlands between June 2017 and December 2018.

PARTICIPANTS

Participants were 312 residents, 305 faculty members, 53 administrators, and 1049 patients from 66 (non)academic hospitals.

MAIN MEASURES

Respondents 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 RESULTS

Attitudes 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).

CONCLUSIONS

Attitudes 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.

High value care education in general surgery residency programs: A multi-institutional needs assessment

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.

How Do Attending Physicians Prepare Residents to Deliver High-Value, Cost-Conscious Care?

PURPOSE

An estimated 20% of health care expenditures are wasteful. Educational interventions aimed at reducing waste by delivering high-value, cost-conscious care (HV3C) often focus on the role of the physician. This study sought to understand how attending physicians, who have a central role in the workplace, prepare residents to provide HV3C.

METHOD

Researchers from Maastricht University in Maastricht, the Netherlands, conducted semistructured interviews between September 2016 and August 2017 with 12 attending physicians who supervise residents in the workplace. Participants were purposefully sampled from 5 institutions throughout the Netherlands to include surgical and nonsurgical attending physicians and hospital- and nonhospital-based physicians. Data collection and analysis were iterative, using principles of grounded theory.

RESULTS

The attending physician's approach to providing HV3C was an important factor in preparing residents in the workplace. Three differences became apparent: priority of HV3C training, feedback on HV3C, and obstacles to HV3C delivery. Results indicate that attending physicians use 3 teaching methods to teach HV3C delivery: Socratic questioning, role modeling, and setting limits. Training was often implicit and ad hoc.

CONCLUSIONS

How attending physicians deal with HV3C themselves influences how they prepare residents in the workplace. To optimize resident training, it may be important to create a supportive environment for HV3C delivery and training. Delivery could be supported by making HV3C a shared goal for attending physicians and residents, thereby providing insight into clinical practice behavior and minimizing the influence of obstacles. Training could be optimized by supporting a variety of teaching methods suitable for daily teaching to stimulate continuous learning in residents.