A High-Value Care Curriculum For Internal Medicine Residents

From the 2019 HVPAA National Conference

Dr. Rachna Rawal (Saint Louis University), Dr. Paul Kunnath (Saint Louis University), Dr. Hala Saad (Saint Louis University), Dr. Alex Lane (Saint Louis University), Dr. Ghassan Daher (Saint Louis University), Dr. Fernand Bteich (Saint Louis University), Dr. Fred Buckhold III (Saint Louis University), Dr. Jennifer Schmidt (Saint Louis University)

Background

The healthcare crisis in the United States is prompting a shift toward a high-value, cost-conscious culture. Physicians develop their ordering practices early in their training, therefore directing high-value care education at residents will have the greatest impact. A needs assessment demonstrated that only 8% of our residents could provide an accurate free-response definition for high-value care with18% of residents reporting previous participation in prior high-value care projects. This need prompted the development of a high-value curriculum.

Objectives

  1. Understand Internal Medicine resident need for high-value care education
  2. Implement high-value care curriculum for Internal Medicine residents
  3. Analyze residents’ reported awareness of high-value care post-implementation

Methods

We designed and implemented a high-value care curriculum targeting Internal Medicine residents. It included six didactic sessions, three interactive case-based sessions (afternoon schools), and incorporation of rapid-fire cases into monthly floor orientation. Objectives included: defining high-value care, applying evidence-based medicine, a “how-to” guide on developing a high-value care initiative, cognitive biases, integrating pathology consults, and applying American College of Radiology (ACR) Appropriateness Criteria. Residents completed pre and quarterly post- surveys consisting of Likert scale, multiple choice and free responses questions.

Results

Pre-intervention data showed 85% of residents correctly selected the definition of high-value care in a multiple-choice question. 8% and 52% of residents distinguished the definitions of “price” and “cost”, respectively. 14% reported familiarity with the ACR criteria and 24% felt comfortable applying those guidelines. After the first afternoon school, the number of residents who felt “very comfortable” recognizing hospital overuse increased from 27% to 52% (statistically significant, p<0.05). 96% felt encouraged to participate in a high-value care initiative in the future. After the second case-based session, 100% felt comfortable with the use and limitations in urine electrolytes. 88% felt comfortable in applying Choosing Wisely guidelines for patient management. After the third case-based session, 90% of residents felt comfortable in considering costs of treatments/tests when making decisions with patients. End of the year survey results are pending.

Conclusion

While the majority of residents could choose the definition of high-value care from a list, they could not generate a free-response definition. This discrepancy highlights that while residents have some basic knowledge of high-value care, they lack the skills to apply and generalize it. Integrating interactive case-based sessions where residents applied Choosing Wisely made them more comfortable in using them. Additionally, residents were more comfortable in addressing cost with their patients.

Clinical Implications

We believe our post-data will support increased resident recognition of overuse and motivation to become involved in high-value care initiatives. Residents will have gained skills to utilize various resources to apply high-value care. By providing residents a diverse curriculum composed of short didactics and case-based sessions, we have created a high-value care foundation on which they can continue to build upon.

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

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