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Implementation of High Value, Cost-Conscious Care Curriculum

APDIM Fall Meeting

in a Community-Based Internal Medicine Residency
Alliance for Academic Internal Medicine
NEW ORLEANS, LA • OCTOBER 2-6 2013 Parul Sud, MD, FACP & Shagufta N. Ali, MD, FACP
D E P T. O F I N T E R N A L M E D I C I N E , M c L A R E N F L I N T M E D I C A L C E N T E R , F L I N T M I C H I G A N

Background Figure 1: Goals and Objectives Figure 2: Overview of Curriculum Dissemination Figure 4: Post-Curriculum Questionnaire about the Discussion
Residents’ Knowledge and Skills about HVCCC
n Cost of health care in the U.S. is increasing at an “unsustainable” rate while quality metrics reveal our n Residency programs are challenged to incorporate increasing demands for training clinically competent,
performance to be much lower than many other countries. ethical professionals, who are tutored in principles of QI, EBM, Patient Safety, and are responsible stew-
ards of the health care resources.
n Up to 30% of health care costs (more than $750 billion per year) are attributable to avoidable “wasted • HVCC Survey Questions SA A N D SD
care.” • Quarterly PLP n AAIM-ACP’s HVCCC has provided us with a practical tool to teach cost-conscious care.
To incorporate the discussions • EBM
n The Alliance for Academic Internal Medicine (AAIM) and the American College of Physicians (ACP) jointly AAIM-ACP’s HVCCC • QI 1. I have sound knowledge of established n Factors promoting sustainability in implementing this curriculum in our program includes the following
created a high value, cost-conscious care (HVCCC) curriculum for internal medicine residents (hvc. evidence-based benchmarks for chronic framework:
curriculum in internal Residents’ medical illnesses, e.g. DM, Asthma.
acponline.org/curriculum.html). medicine residency Interactive
Self- ❖ Faculty development meetings.
training at a community Workshops 2. I am confident that my practice is in compliance
n The American Board of Internal Medicine (ABIM) and over 30 other specialties participate in the “Choos- Reflection
❖ Well-established QI curriculum (required component of scholarly activity for all residents).
ing Wisely” campaign to “question” the necessity of five interventions or tests in each specialty. hospital with EBM.
❖ Well-established EBM curriculum.
n The Accreditation Council for Graduate Medical Education (ACGME), under its Systems-Based Practice core 3. I am more aware of areas that need
competency, states residents/fellows are “expected to incorporate considerations of cost awareness and Apply to Small improvement within my hospital /clinic. ❖ Weekly Ambulatory tutorials including a reflective component, the Personal Learning Plan (PLP).
risk benefit analysis in patient care.” Patient Group
Care Sessions 4. I try to pick interventions that will provide
n It is suggested that this be inculcated as a “seventh” competency. To emphasize cost- improved outcomes.
To raise residents’ • Complete Quality • Ambulatory block
effective, evidence- improvement rotations
n Our pre-curricular questionnaire confirms residents’ deficits in HVCCC. self-awareness 5. I identified a clear intervention that was of low
based medicine (EBM) projects based on
regarding • MKSAP review value that I STOPPED doing.
to achieve quality HVCCC sessions
“wasted care”
patient care.  6. I identified a clear intervention that was of high
value that I STARTED doing.
Implementation Methods
7. I understand the concept of high /low Cost vs. n Did not use real time costs for our own cases. Relied on cases and costs from the HVCCC modules.
n A one-hour faculty development session. high and low Value.
n Shifts in costs and charges due to changing reimbursements, insurances and formularies.
Figure 3: Goals and Objectives 8. I understand the system of health insurance.
n A four-hour interactive workshop disseminating the first 3 modules of HVCCC. n Dissemination during ABR was non-sustainable due to demands on faculty time.
n Subsequent modules presented at noon conferences. 9. I understand that the actual Costs of tests or n A different set of questions were asked on the pre- and post-curricular surveys. The two could not be
treatment are not the same as what is Charged compared by a statistical test.
n Residents’ knowledge, skills and attitude were assessed by pre-and post-curricular questionnaires Table 1: HVCCC Modules to the patient or insurance.
distributed by Survey Monkey.™ Self-Reflection, Varun Golla – R3 n Lack of a reliable tool to measure the effectiveness of this curriculum.
H I G H VA L U E C O S T- C O N S C I O U S C A R E – P E R S O N A L L E A R N I N G P L A N 10. As a result of the HVCCC curriculum I
n Residents presented cases based on self-reflection upon recent clinical experiences, identifying oppor-
have gained a better understanding of the
tunities for application of HVCCC using the “traffic signal” approach. importance and need for Quality Improvement
1. Introduction to Health Care Value Case # 1
n Principles of HVCCC incorporated in the annual mandatory Quality Improvement (QI) workshop, and Projects.
A 58-year-old AA male presented with acute dyspnea and sharp
resident teams included cost-conscious care as they formulated their QI projects. 2. Healthcare Waste, Costs, & Over-ordering of Tests chest pain since 6 hours. He was in his usual state of health until 11. The HVCCC is highly relevant to my clinical
n Work sheets from Module 3 incorporated in a mandatory one day Evidence-Based Medicine (EBM) workshop 6 hours ago when he noticed these symptoms. His past medical practice.
3. Health Insurance
for PGY-1 residents. problems included DM and HTN which were adequately controlled.
12. As a result of this curriculum, I am likely to Conclusion / Future Direction
His vitals upon presentation were normal. Physical exam showed change my test ordering behaviors.
n HVCCC marked items emphasized in annual MKSAP review. 4. Healthcare Costs & Payment Methods
normal breath sounds with no added sounds and heart exam was
n Escalating costs of health care combined with suboptimal health care quality reports, serve as a wake-up
5. High Value Biostatistical Concepts normal. He underwent a CT of chest with IV contrast that showed
call to all U.S. physicians.
a subsegmental right-sided PE. He was started on IV heparin and
6. High Value Screening & Prevention later changed to warfarin. Hypercoagulable panel was ordered. n While most residency educators emphasize EBM and critical appraisal, we have neglected to address
Evaluation STOP
Graph 1: Residents’ Responses to the Questionnaire cost-conscious care.
7. Balancing Benefits with Harms & Costs about the Residents’ Knowledge and Skills to n Furthermore, unrestrained defensive medicine provides poor role-modeling for learners. By implement-
n A pre-workshop questionnaire based on the HVCCC module content revealed the following (number of Hypercoagulable panel is not reliable in acute PE patients on hep-
Practice HVCCC after Implementing the Curriculum ing the HVCCC curriculum, we hope to inculcate principles of best practice and cost consciousness
respondents 22/36): 8. High Value Medication Prescribing arin and warfarin. It is not indicated in patients older than 50 years
among our residents and faculty.
❖ 73% of residents did not have a good understanding of medical insurances in the USA. with pulmonary emboli.
9. Overcoming Barriers to High Value Care 100.0% n By building the AAIM-ACP’s HVCCC curriculum on our existing framework, we anticipate it will be sus-
❖ 68% admitted to ordering tests because of diagnostic uncertainty.
Case # 2 90.0%
❖ 68% admitted to ordering basic tests in all patients. 10. Local High Value Quality Improvement Project A 50-year-old Caucasian male presented to ED 2 hours after hav- 80.0%
❖ 36% refer to specialists and order tests because of fear of malpractice.   ing a possible seizure vs. syncope episode. Vital signs were nor- 70.0%

n Post-curricullar questionnaire (number of respondents 16/36 ): mal. Physical exam was unremarkable. A whole battery of tests 60.0%

❖ 100% of responders agreed or strongly agreed that they understood the concept of “cost vs. value” (Q 7). was ordered including serum prolactin level. 50.0%
❖ 100% of responders agreed or strongly agreed that they understood the “relevance” of high value cost STOP
conscious care (Q 11). Prolactin level cannot be used to differentiate between seizure and References
❖ 100% of responders agreed or strongly agreed that they were “likely to change test ordering behav- syncope. Sensitivity of prolactin level is poor so a normal prolac- 10.0% 1. Baker DW, et al. Design and Use of Performance Measures to Decrease Low-Value Services and 4. Cassel CK, Guest JA. Chosing Wisely: Helping physicians and patients make smart decisions
Achieve Cost-Conscious Care. Ann Intern Med. 2013;158:55-59. about their care. JAMA 2012;307:1801-1802.
iors” (Q 12). Parul Sud, MD, FACP and / or Shagufta Ali, MD, FACP tin level is insufficient to exclude epileptic seizure. 0.0% 2. Smith CD. Teaching High-Value, Cost-Conscious Care to Residents: The Alliance for Academic 5. Qaseem A, Alguire P, Dallas P, Feinberg LE, Fitzgerald FT, Horwitch C, Humphrey L, LeBlond

❖ More than half indicated that they were “more aware of areas for improvement within their hospital or For further information, McLaren Flint Medical Center Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Internal Medicine – American College of Physicians Curriculum. Ann Intern Med. 2012;157:284-
R, Moyer D, Wiese JG, Weinberger S. Appropriate use of screening and diagnostic tests to
foster high-value, cost conscious care. Ann Intern Med. 2012; 156:147-149.

clinic” (Q 3), which would be a good basis for building future QI projects. please contact: Dept. of Internal Medicine Strongly Agree Agree Neutral Disagree Strongly Disagree 3. Owens DK, Qaseem A, Chou R, Shekelle P. High-value, cost-conscious health care: concepts 6. Weinberger SE. Providing high-value, cost-conscious care: a critical 7th general competency
for clinicians to evaluate the benefits, harms, and costs of medical interventions. Ann Intern for physicians. Ann Intern Med. 2011; 155:386-388.
401 S. Ballenger Hwy. • Flint, Michigan 48532 Med. 2011; 154:174-180.