Parsimonious Practice: Ideas for Implementing a High Value Care Curriculum

Transcription

1 Parsimonious Practice: Ideas for Implementing a High Value Care Curriculum Anna K. Donovan, MD Maggie K. Benson, MD Thomas D. Painter, MD Peggy B. Hasley, MD, MHSc Definition High Value Care (HVC): Care that achieves better outcomes at lower costs 1 Reduction of low value care 2 Moving away from the concept of cost 1. Cosgrove et al, IOM Roundtable Discussion Paper, June Weiner, LDI Health Economist, April 2013.

2 Definition (cont.) One important first step in high value, cost conscious care is to consider costs as not just the price of the test but including all the downstream costs, benefits, and potential harms to each intervention. A high cost intervention may provide good value because it is highly beneficial, whereas a low cost intervention may have little or no value if it provides little benefit or increases downstream costs. The curriculum does not focus exclusively on reducing cost, but instead teaches residents to consider value by balancing benefits with harms and costs Logio, Academic IM Insight, Discussion Questions What are you currently doing at your local institutions to teach High Value Care (HVC)? What do you find challenging about teaching HVC concepts?

3 Workshop Overview Resources including ACP Curriculum (15 minutes) Small Group Discussion (30 minutes) Debrief Small Groups (10 minutes) Spotlight on Pittsburgh (10 minutes) Assessment Tools (10 minutes) Questions (10 minutes) Good news! You don t have to go it alone.

4 ACP: High Value Care Clinical Recommendations Physician Resources Patient Resources Curriculum ACP / AIMM High Value Cost Conscious Curriculum Target audience: IM residents and faculty Case based modules Delivered over 60 minutes Can integrate into multiple venues Download (free!) from ACP website Include: Powerpoint presentation Facilitator guide Accessory material

5 Example: Module One Introduction to Health Care Value Overview of the problem and IOM report Case: Post op pulmonary embolism Introduction to Five Steps Approach Small groups: Discuss diagnosis of PE What tests are the benefits, harm and cost of each test? Small groups: Inpatient vs Outpatient work up using sample bill What tests are necessary, what can be eliminated? Summary of take home points Ask learner to commit to a behavior change ACP Modules: Topics Introduction to Health Care Value Waste, Costs and Over Ordering Health Insurance Costs and Payment Models Biostatistical Concepts Screening and Prevention Balancing Benefits with Harm and Cost Medication Prescribing Overcoming Barriers Local QI

6 ABIM: Choosing Widely Campaign to reduce unnecessary tests and procedures Now comprised of > 25 specialty organizations Each has compiled Five Things Patients and Physicians Should Question Partnering with Consumer Reports: Patient friendly Material

7 Healthcare Blue Book Target audience: patients Lists the fair pricing by geographic area Includes diagnostic tests, medications, physicians Healthcare Blue Book

8 AHRQ: epss Electronic Preventive Services Selector Free app for mobile devices Input age and sex Get USPSTF recommendations on screening Academic Programs Do No Harm Project: UC Denver List of High Value Care articles Collection of student and resident clinic vignettes Cost Conscious Care: University of Alabama: Emphasize ACP Curriculum Collection of other resources

9 Breakout Session Part One (20 min) Practical ways to implement in 4 settings: Inpatient Outpatient Consultative Medicine Morning Report Use the table as a guide for discussion Breakout Session Part Two (10 min) If you haven t started to do so already, discuss strategies for evaluating the curricular interventions already discussed with your group

10 Summary of Breakout Sessions 10 min Teaching High Value Care A Strategy from the University of Pittsburgh

11 A Culture Change Surround the residents with this curriculum Depends upon buy in from the faculty Multifaceted curriculum Intern Ambulatory Block Noon Time Conferences Continuity Clinic Wards Morning report Intern Ambulatory Block Small Group Session Based Upon ACP Module High Value Topic Clinical Context 1 Introduction to High Value Care 2 Health Care Wastes and Costs Headache Evaluation 9 Overcoming Barriers Back Pain I Need an MRI Pocket Hand Out on Principles and Web Based resources Pocket Guide to Diagnostic Tests, Nicoll, D. et al. Reading List: The Bitter Pill : Time Magazine May 2013 First Do No (Financial) Harm, Moriates et al. JAMA 2013

12 Noon Time Conferences Module High Value Topic Clinical Context 3 Health Insurance Ruptured appendix, treatment for osteomyelitis 4 Health Care Costs and Payment Models Soccer injury, asthma 7 Balancing benefits with harms/costs Prostate cancer screening, Chest CT to diagnose pneumonia 8 High Value Medication Prescribing Allergic rhinitis, switching to generics Continuity Clinic Integrate ACP Module (6): Screening and Prevention into Pre clinic conference Presents a case of a periodic health exam in a 57yo smoker. Asks the learners: What would you recommend for preventive care? Elements of a useful screening test Cost effectiveness and QALYs Overdiagnosis and Pseudodiagnosis Lead Time Bias USPSTF, Electronic Preventive Services Selector (epss) Motivational interviewing on smoking cessation

13 Continuity Clinic Post Commonly ordered tests with charges in precepting room Post 5 Commonly ordered tests that should be Chosen Wisely Ambulatory Progress Note Feedback includes discussion of learners high value care Recognition of patients insurance status Choosing medicines on the $4 plan Avoiding shot gun work ups Documentation of discussion regarding downstream affects of screening Attending Rounds Reflection at discharge Did we commit any errors? Did we do too many interventions? Did we address all the needs of the patient? Feedback on expenditures Look at a bill

14 Morning Report Celebrating restraint Make a pragmatic shift, no longer looking for zebras Likelihood Ratio Nomogram Presenting resident will be able to discuss pretest probability of disease and the LR+ and LRfor tests under consideration Evaluation of High Value Care Curricula

15 Varkey et al: Study Design Systematic Review of GME level of costeffective medical practice curricula 40 articles met eligibility criteria, 27 for IM Most focused on cost awareness and containment Educational strategies included didactics, selfdirected, interactive, experiential, or multiple No comprehensive curriculum 1. Varkey et al, Journal of Evaluation in Clinical Practice, Varkey et al: Curricular Evaluation Improved clinical outcomes (80%) Lab and encounter charges X rays Length of stay Number of tests ordered Improved learner centered outcomes (8%) Doctors knowledge and attitudes Negative studies (12%)

16 University of Pennsylvania Curriculum Survey evaluating feedback practices including: Utilization of healthcare resources Knowledge about prices of commonly ordered tests Administered to all IM residents Tailored curriculum of biweekly small group didactics and discussion Benchmarking reports on individual providers resource utilization with attending feedback 1. Dine et al, JGME, UCSF Curriculum Goals of promoting cost awareness, improving physician attitudes, cultivating more costeffective physician behavior Multifaceted approach including: Didactics Experiential case review for interns Monthly case based noon conference Post conference survey to attendees to collect data on effectiveness of conference 1. Moriates et al, JAMA Intern Med, 2013.

17 Evaluation of the Pittsburgh Curriculum Global, cross sectional survey of all Internal Medicine Residents 15 items plus three open ended questions Included in the annual residency program survey Assessment of residents knowledge, use of skills, and attitudes Purpose: Feedback to inform future curricular efforts Assessment of improvement pre and post curriculum Pittsburgh Survey: Knowledge I am familiar with the relative costs of the most common tests that I order on inpatients. I am familiar with the relative costs of the most common tests that I order on outpatients. I know how to find costs for commonly ordered diagnostic tests. I know how to access evidence based guidelines when deciding which tests to order for a given condition.

18 Pittsburgh Survey: Use of Skills When I order a diagnostic test, I consider how the results will change my management of the patient. When I order a test, I consider the risks (nonfinancial costs) to the patient. When I order a diagnostic test, I consider the financial costs to the individual patient. Pittsburgh Survey: Use of Skills (cont.) When I order a diagnostic test, I consider the financial costs to the healthcare system. When choosing between various diagnostic tests, I compare the evidence basis for each test to help make a selection. I feel pressure from attending physicians (either generalists or specialists) to order more tests than I think are necessary for my patients.

19 Pittsburgh Survey: Attitudes Physicians have a responsibility to reduce healthcare spending. Trying to save money in patient care will strain relationships between patients and their physicians. In the majority of cases, physicians are not responsible for wasteful financial practices in healthcare. Rationing is necessary to reduce healthcare costs. Unless a patient has opted for a palliative approach to their medical care, physicians are obligated to do as comprehensive a medical work up as possible for a medical problem regardless of cost. Pittsburgh Survey: Open Ended Questions What do you find most challenging about providing High Value Care? Since you started your residency training, what have you been taught about High Value Care (either formally or informally)? What topic would you most like to learn more about with regards to High Value Care?

20 Questions? "To improve emergency room throughput we've replaced the front door with a CT scanner." 1. ACP Hospitalist Weekly, ACP Curriculum References Choosing Wisely and Consumer Health Reports care/ epss

21 References: Other Institutions Alabama at Birmingham: costconscious care UC Denver: dicalschool/departments/medicine/gim/educatio n/donoharmproject/pages/welcome.aspx

22 AAIM-ACP Curriculum on High Value Cost Conscious Care An Overview of 10 modules 1. Introduction to Health Care Value- This module defines the problem of low value care. Benefits, harms and costs including downstream costs of a post-op PE and inpatient versus outpatient management of a suspected DVT are reviewed. Five steps of high value cost conscious care are presented. 2. Health Care Waste, Costs and Over-Ordering Tests The Choosing Wisely reference set is introduced as part of a discussion on brain imaging at the time of headache diagnosis. Reviews the questions that should be asked before ordering a test. In a case of decompensated congestive heart failure, the costs of tests and ways to eliminate unnecessary testing are reviewed. 3. Health Insurance This module discusses the financial consequences of catastrophic care in the context of a patient with a ruptured appendix. Barriers to health care for the uninsured are addressed. The basic concepts of insurance, are reviewed. A case of a patient requiring 6 weeks of antibiotics for osteomyelitis is presented. Learners determine if insurance would cover outpatient treatment. 4. Health Care Costs and Payment Models This module addresses the complexity of health care costs. Health care reimbursement models are reviewed as well as the means by which health care is paid for. Learners brainstorm about reasons for inappropriate referral to the Emergency Department. 5. Biostatistical Concepts you Need to Know Statistics in diagnosis and treatment are reviewed. Application of the use of sensitivity, specificity, PPV, NPV, LR, RR, OR, NNT and NNH are discussed using a case of aspirin in primary and secondary prevention of ischemic CAD. 6. Screening and Prevention This module presents a case of a periodic health exam to introduce the concepts a useful screening test, cost-effectiveness and QALYs. The USPSTF electronic preventive services selector ) (epss) and a discussion on motivational interviewing are then presented. 7. Balancing Benefits with Harms and Costs A case of a 56 you whose friend has just died of prostate cancer and is requesting a psa test orients this module. Harms and costs of prostate cancer and shared decision making are then addressed. A case of using chest CT scans to diagnose pneumonia is used to point out the harms and costs of testing. 8. High Value Medicine Prescribing This module reviews the influence of pharmaceuticals on physician prescribing practices by discussing choice of medicines to treat allergic rhinitis and conjunctivitis. Methods used to switch patients to generics are shown along with a presentation on over-prescribing and adherence. Multiple web resources are presented. 9. Overcoming Barriers This module presents the contrast between guidelines and actual practice in the setting of a case of a patient who requests an mri to evaluate back pain. Tips on talking to patients about not doing things are presented and internet resources on cost are presented. 10. Local Quality Improvement This module can be used to assist programs to institute a QI project aimed at the provision of high value care at their own site.