Teaching High Value Medication Prescribing: A Case-Based Exercise

From the 2022 HVPA National Conference

Nathan Yee (Bachelor of Arts (BA), University of Massachusetts Chan Medical School), David Fish M.D.  

Background

Medication overuse and other common prescribing pitfalls are significant contributors to waste in healthcare spending. Approximately 30% ($750 billion annually) of U.S. healthcare spending goes to waste,1 and 10% ($260 billion) of U.S. healthcare costs can be attributed to prescription drugs.1 Therefore, medical students must receive additional training on high-value prescribing principles.   

Objective

Develop a curriculum that equips medical students with a set of principles for improving value when managing patient medication lists.

Methods

Third-year medical students participated in a case-based exercise with physician-led small groups. Students were shown a case of an elderly female patient presenting with signs of heart failure exacerbation and a complex medication list. The small groups discussed a series of questions focused on addressing value deficits in the medication list, as well as barriers to medication adherence. Students then collaborated to generate a list of guidelines for high value medication prescribing. Their respective lists were compared to a list of 7 Core Principles of High Value Prescribing2: Have a compelling reason for each medication, keep the medication list short, evaluate affordability before starting a new prescription, prescribe generics when possible, collaborate with pharmacists, utilize the teach-back method to increase patient understanding, and consider frequency of dosing as a compliance predictor. Students were introduced to Choosing Wisely guidelines as part of this session.

Results

A post-survey was conducted assessing medical student attitudes towards high value prescribing, self-efficacy regarding value-related patient interactions, and the case-based session delivery. 34 students responded to the survey. 73.5% of respondents agreed that the session increased their confidence in applying high value prescribing principles. 73.5% agreed that they were more likely to consider high value prescribing principles in their clinical practice because of the session. A majority of respondents agreed that they were confident in their ability to discuss the value of medications with patients (73.5%) and utilize the teach-back method (85.3%). A minority of students reported confidence in their ability to discuss cost with patients (32.4%). 70.6% agreed that they were more likely to reference Choosing Wisely guidelines because of the session. 79.4% agreed that case-based learning was a good way to teach high-value prescribing principles during the session.

Conclusions

This case-based exercise impacted third-year medical student attitudes towards applying principles of value-based care within the context of medication prescribing. Students expressed confidence in their ability to discuss medication value and utilize the teach-back method, but a relative lack of confidence in their ability to discuss cost. Students favored the case-based discussion format as a means of presenting this material. Finally, exposure to Choosing Wisely guidelines increased likelihood that students would reference them in the future. Further instruction will aim to build on these core principles and apply them in various other contexts.

This session had limitations as it was generated as a standalone session taught at a single institution. No pre-survey data regarding the session was gathered, so prior knowledge of high value prescribing was not assessed.

Clinical Implications

Teaching guiding principles for high value prescribing encourages medical students to optimize cost, minimize side effects, increase patient adherence, and eliminate unnecessary medications in their clinical clerkships and beyond.

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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