Shark Tank: High Value Care Curriculum for Internal Medicine Interns. Heather Sateia, MD April 17, 2015

Transcription

1 Shark Tank: High Value Care Curriculum for Internal Medicine Interns Heather Sateia, MD April 17, 2015

2 Outline Definitions Current state of HVC education My proposed project and why it matters Why my project will work How I ll prove it!

3 High Value Care Care that balances clinical benefit with cost and harms, with the goal of improving patient outcomes

4 Current State: HVC Education ACGME expects that, [Each resident] identifies forces that impact the cost of health care, and advocates for, and practices cost-effective care. The aspirational level states that each resident teaches patients and healthcare team members to recognize and address common barriers to cost-effective care and appropriate utilization of resources. In 2012, approximately 15% of 295 programs, had formal curriculum in high value care, 49.8% were in the process of developing one. Of these curricula, only 6 programs (15.4%) incorporated simulation-based education (Patel MS, 2014).

5 What makes this HVC curriculum different? 1. Outpatient-focus Recent study showed family medicine residents at 3 programs, ordered on average 3.3 to 5.7 inappropriate tests for each of their clinic patients (Fung D, 2015) 2. Communication skills Systematic review showed that patients overestimated benefits and underestimated harms for 2/3 rds of the studied interventions regardless of type of service, clinical context, or patient population (Hoffman TC, 2014). Doctors believe 71% of breast cancer patients rate keeping their breast as a top priority, only 7% of patients rate this as top priority (Lee CN, 2010) Use of decision aids and shared decision making led to approximately 1/3 rd fewer surgical procedures according to a systematic review of national and international surgical procedure frequency (Birkmeyer JD, 2013).

6 The Curriculum: Implementing High Value Care in the Outpatient Encounter Osler interns on their third 2-week ambulatory rotation (~6 interns every 2 weeks). 2 Friday mornings, 2 hours each session.

7 Pre-Session Session 1: HVC Opportunities and Barriers Session 2: Communicating HVC Concepts Post-Session Physicians Education and Assessment Center (PEAC) module on Choosing Wisely Evidence based medicine curriculum during second 2-week ambulatory rotation Didactic: Reintroduction to high-value care concepts Review relevant biostatistics Small group discussion: Chart review (using chart-stimulated recall tool) Discussion of barriers to high value care in the clinic Didactic: Review components of patient-centered communication and shared-decision making Define appropriate communication of risk and benefits with patients Small group: Role play Standardized patient encounter High-value care mini- CEX performed in clinic (clinical evaluation exercise). Independent chart stimulated recall exercise.

8 HVC Communication Skills Objectives: By the end of the session, IM interns will demonstrate components of patient-centered communication, including avoidance of medical jargon, discussion of risk/benefits, outlining options, eliciting patient preference/beliefs/values, and use of decision aids. IM interns will demonstrate how to effectively communicate information regarding risk, probability, and other HVC concepts to patients using patient centered communication.

9 HVC Communication Skills: Curricular Components Didactic Communicating risk Shared decision making (5 step) Decision support aids Standardized Patient Role Play

10 Standardized Patient Encounter Single case, 6 interns per 2-week block, each with a standardized patient (SP) SP and faculty observer have checklist and serve as evaluators Feedback from SP following encounter Group debrief/reflection with interns and faculty facilitator following the experience

11 Role Play Scripted role play case Interns play the physician Interns or faculty play the patient Background information and scripted potential questions provided Checklist to help elucidate expectations and serve as evaluation tools Video vignette of best practice encounter

12 Assessment/Evaluation High value care mini-cex Performed by clinic faculty before and following HVC curriculum Resident questionnaires Confidence, attitude, realism Utility of the feedback received Compare between role play and SP groups

13 Budget #1: SP Estimate of Costs Simulation Center/SP 8,000 Administrative 500 Total $8,500 Itemized Estimate of Costs Description Cost SPs: Preparation and performance Proctor Coordinator Costs: Project planning, coordination, scheduling, recruitment, event management, payroll, etc. Facility fee: classroom (1 hr) Facility fee: 6 simulation examination rooms (1.5 hrs) $3,750 $1,800 $1,600 Miscalleneous costs: Parking $650 Administrative: Payroll, etc. $100 Total Estimated Project Costs $7,900

14 Budget #2: SP versus Role Play Itemized Estimate of Costs Description Cost Estimate of Costs Simulation Center/SP 3,800 Video 1,000 Total $4,800 SPs: Preparation and performance $1,250 Proctor Coordinator Costs: Project planning, coordination, scheduling, recruitment, event management, payroll, etc. Facility fee: classroom (1 hr) Facility fee: 3 simulation examination rooms (1.5 hrs) $1,450 $800 Miscalleneous costs: Parking $250 Administrative: Payroll, etc. $50 Total Estimated Project Costs $3,800

15 Feasibility Mentor: Gail Berkenblit, Clinic Director, Associate Program Director for Ambulatory Education, Osler Medicine Training Program Team: Amit Pahwa (currently implementing HVC curriculum for medical students) Sara Mixter, Associate Program Director for Ambulatory Education Carol Fleishman, simulation center Najlla Nassery, Belinda Chen, Dave Kern Curriculum development Time: 2-hour weekly block Sustainability: data from our pilot study will provide the basis for additional grant applications to continue funding the curriculum.

16 References Patel MS, Reed DA, Loertscher L, McDonald FS, Arora VM. Teaching Residents to Provide Cost-Conscious Care: A National Survey of Residency Program Directors. JAMA Intern Med. 2014;174(3): doi: /jamainternmed Fung D, et al. Test ordering for preventive health care among family medicine residents. Canadian Family Physician. 2015; 61: Lee CN, Hulsman CS, Sepucha K. Do patients and providers agree about the most important facts and goals for breast reconstruction decisions? Ann Plastic Surg 2010;64:563-6 Birkmeyer JD, Reames BN, McCulloch P, Carr AJ, Campbell WB, Wennberg JE. Understanding of regional variation in the use of surgery. Lancet. 2013;382(9898): Hoffmann TC, Del Mar C. Patients Expectations of the Benefits and Harms of Treatments, Screening, and TestsA Systematic Review. JAMA Intern Med. 2015;175(2): doi: /jamainternmed Carvalho et al.: Teaching communication skills in clinical settings: comparing two applications of a comprehensive program with standardized and real patients. BMC Medical Education :92. Fallowfield L, Jenkins V, Farewell V, Saul J, Duffy A, Eves R: Efficacy of a Cancer Research UK communication skills training model for oncologists: A randomised controlled trial. Lancet 2002, 359: Epstein RM, Hundert EM: Defining and assessing professional competence. JAMA 2002, 287: Duffy FD, Gordon GH, Whelan G, Cole-Kelly K, Frankel R, Buffone N, Lofton S, Wallace M, Goode L, Langdon L: Assessing competence in communication and interpersonal skills: The Kalamazoo II report. Acad Med 2004, 79: Bokken L, Rethans JJ, Scherpbier A, van der Vleuten C: Strengths and weaknesses of simulated and real patients in the teaching of skills to medical students: A review. Sim Healthc 2008, 3: Bosse HM, Schultz J-H, Nickel M, Lutz T, Möltner A, Jünger J, Huwendiek S, Nikendei C: The effect of using standardized patients or peer role play on ratings of undergraduate communication training: A randomized controlled trial. Patient Educ Couns 2012, 87:

17 Questions?

18 Carvalho et al. BMC Medical Education :92 doi: /

19

20 Description Itemized Estimate of Costs SPs: Preparation and performance Cost $5,500 Proctor $475 Coordinator Costs: Project planning, scheduling, recruitment etc $2,100 Facility fee: classroom (1 hr) $100 Facility fee: 6 simulation examination rooms (2 hrs) $600 Miscalleneous costs: Parking $1,050 Administrative: Payroll, etc. $100 Total Estimated Project Costs $9,925