Pediatric Residents’ Experiences with High Value Care

From the 2021 HVPAA National Conference

Emma Nathaniel (University of Colorado School of Medicine and Children’s Hospital Colorado), Michael Tchou, Barry Seltz, Alexis Ball, Sheilah Jiménez

Background

Residents are expected to incorporate consideration of cost awareness into patient care. Yet, resident self-reported practice of high value care (HVC) varies and understanding of resident perspectives on trying to practice HVC in the clinical setting is limited.

Objective

To explore pediatric residents’ experiences with HVC in the clinical setting.

Methods

We performed a qualitative study (February-November 2020), with a phenomenological epistemology, using focus groups (n=5) and interviews (n=3) of pediatric residents at a large academic children’s hospital. We used a semi-structured interview and focus group guide focusing on resident experiences with HVC and their perceptions of institutional HVC practice. Data were analyzed using the constant comparative method. Codes were built using an iterative approach and organized into categories that described themes. Sampling continued until reaching saturation.

Results

Twenty-two residents (n= 10 interns, n= 12 PGY-2/PGY-3) participated. Data analysis yielded five themes: Resident Practice, Institutional Culture, Patient Factors/Family Experience, Education, and Incidental Findings (Table 1 shows illustrative quotes). Residents described practicing HVC but felt limited by clinical inexperience. Some residents feared missing diagnoses, but few worried about liability. Autonomy in patient care decisions encouraged HVC; even low value interventions, when residents observed their minimal usefulness, provided important learning.

Communicating reasons for decisions to families and staff promoted HVC though impeded by time constraints and cognitive fatigue. Consistent messaging, when it occurred, to families from interdisciplinary team members supported HVC. Residents described inconsistent HVC practice due to variation by clinical setting, attending physicians making final patient care decisions, and perceived need to adhere to all consultants’ recommendations. Residents struggled with studies that wouldn’t change management but would improve family experience.

Practicing HVC was simple for patients with common illnesses but less clear for those with medical complexity or rare diagnoses. Residents valued informal HVC discussions but felt more education, such as greater cost transparency, was needed. Finally, incidental abnormalities identified on screening laboratory studies led to perceived low value care.

Conclusion

Residents often practice HVC, but they face several complex challenges in a large academic health center. Resident-level factors, institutional culture, patient complexity, family experience, and need for greater cost transparency all influenced residency HVC practice.

Implications

Residency program curricula and broader institutional work are needed to help residents mitigate multiple challenges associated with trying to practice HVC. Further work is needed to understand the role of autonomy in value-based decision-making and its impact on resident learning at a teaching institution.

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