Medical residents need more training on how to reduce healthcare costs while improving patient outcomes in the clinical setting, according to a study published by the American College of Physicians.
The study was designed to measure residents’ knowledge of how to balance benefits with harms and costs of medical interventions – tests and treatments – using specific case vignettes, explains Dr. Cynthia Smith, senior physician educator at the American College of Physicians. Achieving that balance is an important part of ACP’s “High Value Care” initiative. The initiative includes a curriculum for residents, co-developed with the Alliance for Academic Internal Medicine, to help doctors and patients understand the benefits, harms, and costs of tests and treatment options for common clinical issues, so together they can pursue care that improves health, avoids harms, and eliminates wasteful practices.
For the study, the American College of Physicians and the Alliance for Academic Internal Medicine identified 38 of 340 questions on the 2012 Internal Medicine InTraining Examination that correlated with the Hig Value Care initiative. (The annual examination, given to over 20,000 internal medicine residents throughout the nation, is designed to help residents and their program directors assess residents’ knowledge of internal medicine and identify areas for improvement.)The 2012 examination was comprised of 170 items that had been used on prior examinations and 170 new items written specifically for that year’s examination, says Smith. The 38 items selected to make up the High Value Care subscore were identified after the items had been edited and selected to be on the examination based on a set of pre-determined criteria. In other words, they were not questions specifically written to measure high value care, she says.
Each reviewer identified items for inclusion in the High Value Care sub-score that concerned one of the following six High Value Care competencies:
- Identifying and avoiding diagnostic tests and therapies that provide no value and have the potential
to harm the patient or increase cost. - Recognizing and treating a condition based on clinical information without further unnecessary diagnostic testing (for example, avoiding diagnostic imaging for mechanical lower back pain.)
- Managing conservatively when appropriate, including allowing adequate time for clinical improvement, observation and monitoring, or comparison to prior studies rather than additional diagnostic testing (for example, obtaining an old chest radiograph to evaluate a “new” pulmonary nodule rather than a chest computed tomography or future radiograph).
- Selecting from among equally efficacious options the diagnostic or therapeutic intervention that offers the best value considering side effects and costs.
- Applying cost-conscious screening and prevention guidelines (considering patient-specific risk and life expectancy in screening recommendations).
- Understanding basic statistical concepts used to evaluate tests or treatments.
“The majority of questions selected to comprise the sub-score were those questions where the answer was ‘managing conservatively,’” says Smith. “To avoid examinees from always selecting the conservative option, we made sure to include questions where conservative management was an incorrect option.
“Many residents still are practicing under the belief that more care is better care, and more aggressive testing and treatment is always better,” she says. “One of our goals in creating and reporting the High Value Care sub-score was to increase resident and program awareness that this is not always the case, and that appropriate conservative management often improves patient outcomes.
“Residents need easy access to cost information in order to incorporate it into their clinical decision making and discussions with patients,” says Smith. “They need to be more actively engaged in identifying opportunities to reduce waste and improve outcomes in the clinical settings where they are training.”
Average Proportion of Residents Who Somewhat or Strongly Agree With the Survey Questions
(among 362 residents)
Overall mean
- 28 percent – I know where to find estimated costs of tests and treatments
- 47 percent – I incorporate the costs of tests and treatments into clinical decisions
- 26 percent – I share estimated costs of tests and treatments with patients
- 72 percent – I avoid ordering unnecessary tests and treatments for patients
- 88 percent – I incorporate patients’ values and concerns into clinical decisions
- 85 percent – I know the benefits and harms associated with common tests and treatments
- 82 percent – I offer patients alternatives of care; considering benefits, harms and costs
- 61 percent – I reduce healthcare waste within my hospital or clinic
Source: Annals of Internal Medicine, Oct. 14, 2014