OPINIONS AND IDEAS Meeting the Milestones Strategies for Including High-Value Care Education in Pulmonary and Critical Care Fellowship Training Katherine R. Courtright1, Steven E. Weinberger1,2, and Jason Wagner1,3 1 Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; 2the American College of Physicians, Philadelphia, Pennsylvania; and 3the Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania
Abstract Physician decision making is partially responsible for the roughly 30% of U.S. healthcare expenditures that are wasted annually on lowvalue care. In response to both the widespread public demand for higher-quality care and the cost crisis, payers are transitioning toward value-based payment models whereby physicians are rewarded for high-value, cost-conscious care. Furthermore, to target physicians in training to practice with cost awareness, the Accreditation Council for Graduate Medical Education has created both individual objective milestones and institutional requirements to incorporate quality improvement and cost awareness into fellowship training. Subsequently, some professional medical societies have initiated high-value care educational campaigns, but the overwhelming majority target either medical students or residents in training.
Currently, there are few resources available to help guide subspecialty fellowship programs to successfully design durable high-value care curricula. The resource-intensive nature of pulmonary and critical care medicine offers unique opportunities for the specialty to lead in modeling and teaching high-value care. To ensure that fellows graduate with the capability to practice high-value care, we recommend that fellowship programs focus on four major educational domains. These include fostering a value-based culture, providing a robust didactic experience, engaging trainees in process improvement projects, and encouraging scholarship. In doing so, pulmonary and critical care educators can strive to train future physicians who are prepared to provide care that is both high quality and informed by cost awareness. Keywords: costs; healthcare quality; medical education
(Received in original form January 15, 2015; accepted in final form February 25, 2015 ) The views expressed in this article do not communicate an official position of the American College of Physicians. Correspondence and requests for reprints should be addressed to Jason Wagner, M.D., M.S.H.P., University of Pennsylvania, Philadelphia Veterans Affairs Medical Center, 3900 Woodland Avenue, A811, Philadelphia, PA 19104. E-mail: [email protected] Ann Am Thorac Soc Vol 12, No 4, pp 574–578, Apr 2015 Copyright © 2015 by the American Thoracic Society DOI: 10.1513/AnnalsATS.201501-035OI Internet address: www.atsjournals.org
Presently, the United States invests more resources in healthcare than any other modern nation, but does not achieve better health outcomes (1). This, in part, suggests that the quality of U.S. healthcare can be improved both by minimizing healthcare waste and ensuring that evidence-based strategies are routinely adopted. To that end, medical educators must embrace teaching trainees about high-value care, which can be defined as care that balances clinical benefit with costs and harms in an effort to improve patient-centered outcomes. Failing to practice high-value care poses substantial risks to both patients and
574
society, given that healthcare costs are a common contributor to financial bankruptcy and threaten to impinge upon competing societal interests (2). Consequently, numerous stakeholders are transitioning toward value-based reimbursement models that incorporate pay-for-performance metrics and incentivize physicians to prioritize cost awareness. High-value care is particularly germane to pulmonary and critical care medicine. The intensive care unit (ICU) is a resourceintensive environment (3), where low-value care commonly exists (4), and evidence
frequently lags in its implementation. In addition, in the outpatient setting, pulmonologists are moving toward screening high-risk patients for lung cancer with serial low-dose computed tomography. This is predicted to substantially increase healthcare costs (5), which will only be compounded if providers offer this service to patients who stand little chance of benefitting (6). Teaching cost awareness during fellowship is essential, given that physician prescribing behaviors appear to be linked to training environments and persist long after training is completed (7). This cultural
AnnalsATS Volume 12 Number 4 | April 2015
OPINIONS AND IDEAS imprinting has led some to call on policy makers to place increasing emphasis on teaching future physicians about highvalue care. Specifically, there is interest in aligning funds for graduate medical education with training programs’ abilities to teach cost awareness as a core competency (8). This article outlines the importance of teaching cost awareness in graduate medical education, and provides strategies to incorporate a high-value care curriculum into pulmonary and critical care fellowship training. Our goal is to spark enthusiasm among medical educators to foster experiences that adequately prepare fellows to be stewards of healthcare resources and lead in providing high-value care.
spending hinge on successful engagement of physicians to practice with a high-value mindset. There is a mounting effort to bring cost-of-care discussions out of the executive suite and to the bedside as an everyday component of patient–physician communication. Several physician-targeted initiatives have emerged to implement cost awareness in everyday practice. These include the American College of Physicians’ High Value, Cost-Conscious Care Initiative (15), the American Board of Internal Medicine Foundation’s Choosing Wisely campaign (16), the Costs of Care Teaching Value Project (17), and the Institute for Healthcare Improvement’s Open School (18).
The Role of Physicians in Determining Value
The Responsibility of Teaching High-Value Care to Trainees
Over a decade ago, the Institute of Medicine published a series of reports that served as a clarion call for physicians to improve healthcare quality, and to resist a laissezfaire response to the untenable costs that stem from the routine waste of healthcare resources (9, 10). Accordingly, physicians play a pivotal role in the success of a valuebased system, as they account for about 80% of healthcare expenditures (11), and are an important source of waste via prescribing nonbeneficial treatments and over-using diagnostic testing. Pulmonary and critical care providers are not exempt from the responsibility to provide appropriate care. For example, patients with chronic obstructive pulmonary disease receive only 55% of recommended care (12), and there is variation in intensivists’ resource utilization patterns without a notable improvement in patient outcomes (13). In a large survey of U.S. physicians, only 27% of respondents felt they had a major responsibility to reduce costs. Instead, physicians felt that lawyers, insurers, pharmaceutical companies, and even patients shouldered this responsibility (14). Interestingly, they also felt that physicians should lead in limiting the overuse of services. Although this may reflect the tension inherent in simultaneously serving individual patients and society, it may also represent that physicians are in denial about how their medical decision making contributes to excess costs. Thus, strategies to reign in
There is a hidden curriculum in medical education that rewards trainees to be poor stewards of healthcare resources. Too often, educators prioritize excessive diagnostic testing in pursuit of an all-encompassing differential diagnosis rather than arriving at the correct diagnosis in an evidence-based and cost-conscious fashion (19, 20). Our patients are literally paying the price. Unfortunately, physicians in training often lack knowledge of the actual cost of care that they provide (21), which may at least partially explain why less-experienced physicians appear to have higher cost profiles compared with their more experienced counterparts (22). Although this also may be explained by different training sites (23) or payment models (22), behaviors learned in post-graduate training should not be overlooked as significant contributors to excessive resource utilization (20). We believe that much of the onus falls on medical educators to teach trainees how to embark on cost-conscious diagnostic and treatment plans (20, 24, 25). In 2011, one of the authors of this article proposed that cost awareness become the seventh general competency of the Accreditation Council for Graduate Medical Education (ACGME) to reinforce the importance of teaching high-value care to medical trainees (8). Subsequently, the ACGME established the Clinical Learning Environment Review Pathways to Excellence, a framework designed to
Opinions and Ideas
improve trainees’ facility with patient safety and quality improvement (26). Under the revised ACGME program accreditation process for fellowship programs, curricular milestones are used to assess the development of trainees across six core competencies. The most recent iteration includes an explicit objective for “incorporating cost-awareness and risk– benefit analysis into patient care” (27). Accordingly, a graduated fellow is expected to “improve the quality and safety of health care at both the individual and system levels” without supervision (27).
Strategies for Teaching High-Value Care Past cost-awareness educational interventions targeted at physicians yielded modest results at best (28, 29). This should not be justification to passively accept the status quo. Instead, programs should be actively engaged in adopting, creating, and testing high-value curricula. To do so, we recommend that fellowship programs focus on four major educational domains: fostering a value-based culture, providing a robust didactic experience, engaging trainees in process improvement projects, and encouraging scholarship. Fostering a Value-Based Culture
Fellowship programs must provide a durable training experience that celebrates cost restraint as opposed to a “moreis-better” approach. To provide rigorous training experiences, programs should begin by embracing a value-based philosophy to appropriately model a highvalue mindset for their trainees. Successful modeling can occur by asking fellows to reflect on how they may be over-using resources and then encouraging them to adopt a “less-is-more” approach when appropriate. In addition, programs should train and support interested faculty to develop successful multifaceted curricula. As with any topic in medicine, faculty expertise and role modeling of desired behavior are prerequisites for changing the culture in the training environment. We believe that professional societies can play a key role in “training the trainers” by developing educational resources that help to facilitate expertise among a growing number of interested faculty. 575
OPINIONS AND IDEAS Although integrating costs in a transparent manner to provide real-time feedback is a valuable way to target physicians in training, many institutions lack the sophistication in their electronic medical record to do so. If capable, we recommend leveraging this “dashboard” technology to provide longitudinal feedback to fellows about their resource utilization patterns. For those programs that do not have this ability, there are still creative ways to promote cost awareness. One simple way to promote high-value care without access to real-time cost data is to improve fellows’ medical decisions by teaching them to order fewer initial diagnostic tests. Although programs largely succeed in training fellows to master comprehensive differential diagnoses, they often fall short on teaching fellows to arrive at a correct diagnosis in a cost-conscious manner. To do so, we recommend the following framework. First, assist fellows to generate a complete differential diagnosis to expand their fund of knowledge. Then, have fellows split this differential diagnosis into three categories: (1) diagnoses that are likely; (2) diagnoses that are less likely, but dangerous to miss; and (3) diagnoses that are less likely and do not warrant emergent investigation. Next, encourage them to pursue an evidence-based diagnostic approach for only the first two categories. Instruct them to only revisit the third category if their initial diagnostic assumptions were incorrect. Modeling medical decision making in this manner reinforces that, although it is important to develop an all-inclusive differential diagnosis, it is wasteful to execute a “shotgun approach” that aggressively attempts to evaluate every diagnosis with a low pretest probability. Providing a Robust Didactic Experience
Several resources for value-driven didactics now exist for medical educators. The University of California, San Francisco, Center for Healthcare Value Training Initiative recently defined a comprehensive set of applicable high-value care competencies aimed at setting a curricular standard for all stages of professional training (30). At that same institution, they implemented a case-based high-value care curriculum that was well received by medicine residents, although outcome measures have not yet been reported (31). In a cost-awareness pilot initiative, The 576
University of Pennsylvania showed that the combination of structured didactics and real-time comparative feedback was feasible for assessing high-value care practices among trainees (21). On a larger scale, a core educational initiative of the American College of Physicians is their High-Value Care Curriculum (32). It is composed of short, case-based sessions that employ a detailed five-step framework for physicians in training to develop a high-value care skillset. For pulmonary and critical care program directors, we recommend assessing incoming fellows to determine if they have completed this coursework in their residency training, and to consider incorporating this curriculum into the didactic schedule early in the first year of fellowship if necessary. Although the cases use internal medicine examples to highlight six topics surrounding healthcare value, one could easily imagine how exchanging cases focused on the pulmonary and critical care “top five” Choosing Wisely lists (33, 34), for example, could effectively tailor this approach for a fellowship curriculum. In addition, the Institute for Healthcare Improvement launched Open School, an online program to advance the healthcare improvement competencies of the next generation of physicians (18). This webbased curriculum offers free access to a range of courses in patient safety, quality improvement, and cost awareness, and provides certification of completion. Alternatively, a fee-based subscription is available to organizations interested in tracking a learner’s progress and performance through the course. This has the advantage of providing a flexible curriculum that fellows can complete on their own, while simultaneously allowing programs to gauge trainees’ development. Institutions should capitalize on faculty expertise in this area, if possible, to expose fellows to key concepts. For example, in response to the most recent iteration of ACGME milestones and Clinical Learning Environment Review, our fellowship program created a 2-year longitudinal curriculum that begins with didactic lectures that occur early in the first year and culminates with fellows conducting their own process improvement projects. The lecture topics address how to promote a culture of patient safety, fundamental concepts and tools used to conduct process improvement projects, and high-value
care principles that emphasize how cost reductions can result in improved safety and quality. Before developing their process improvement project, each first-year fellow leads a multidisciplinary morbidity and mortality conference in which he or she presents a case vignette that highlights a need for process improvement. The fellow then meets with faculty leadership to conduct a root cause analysis. This approach provides fellows with an early recognition of the importance of high-value care and prepares them for the next phase of their system-based training. Engaging Trainees in Process Improvement Projects
There are several ways to engage fellows to facilitate cost awareness. One powerful way is to have them design and conduct process improvement projects. For example, physicians at the University of California, San Francisco successfully reduced resident ordering of costly nebulized therapies for hospitalized patients through a pilot educational program called “Nebs No More after 24.” They saved roughly $250,000 annually and improved quality by shifting respiratory therapists’ time away from providing low-value therapy toward instructing patients on proper inhaler technique (35). In critical care medicine, a “less is more” approach often results in superior outcomes (4). Recently, an ICU-specific framework for teaching and promoting high-value care was developed (36). This framework is composed of six elements that spell out the aptly named mnemonic, TARGET, to encourage busy ICU physicians to pause for consideration of these high-value care practices. The specific components are: talk to patients about their preferences, ask for outside tests, avoid routine and/or repeated tests, prescribe generic medications, educate about costs, and transfuse appropriately (36). Involving fellows in value-based process improvement projects is an effective way to provide experiential learning that can be captured by training programs to longitudinally assess trainees’ progression. To do so, programs should partner with existing hospital leadership in quality improvement to select projects that are aligned with institutional priorities. Furthermore, we recommend that programs assist fellows to select projects that fulfill the “FINER” criteria (37). Within pulmonary and critical care
AnnalsATS Volume 12 Number 4 | April 2015
OPINIONS AND IDEAS medicine there are several areas of potential interest to merge process improvement with high-value care. Examples include improving the degree to which your institution’s specialty is “choosing wisely,” identifying over-utilized resources (e.g., computed tomography angiography, echocardiography, and pulmonary function testing in the absence of respiratory symptoms) and devising action plans to decrease utilization, and evaluating patterns of care transitions. Medical educators can accelerate the high-value care movement by creating and disseminating curricular innovations. For example, in a recent joint venture between the American Board of Internal Medicine Foundation and Costs of Care, the “Teaching Value and Choosing Wisely Challenge” used crowdsourcing to solicit a diverse number of accessible approaches to teaching high-value care that are generalizable to training programs (38). Encouraging Scholarship
Fellows should be provided with training experiences that build their knowledge,
provide them with opportunities to conduct process improvement projects, and assist them in producing scholarly work. Depending on the scope of the project, highvalue care scholarship can be submitted as a perspective piece centered on a case vignette (39), as an abstract describing innovations in fellowship education, or as a manuscript to journals that publish quality improvement projects or assessments of novel curricula. For the advanced research fellow, scholarship can include improving the methodology of implementation science, randomized trials of quality improvement interventions, and cost–benefit analyses. Akin to successful research training programs, we encourage fellowship programs to foster a supportive environment to assist trainees in carrying out value-based scholarship. This includes both work-in-progress sessions, where trainees can present their work to receive useful feedback about the design and execution of their projects, and dedicated mentorship to develop important academic skills, such as scientific writing,
References 1 OECD. Health at a glance. 2013 [accessed 2014 Jan 11]. Available from: http://www.oecd.org/els/health-systems/health-at-aglance-2013.pdf 2 Cohen RA, Kirzinger WK. Financial burden of medical care: a family perspective [updated 2014 Jan 28; accessed 2015 Mar 24]. Available from: http://www.cdc.gov/nchs/data/databriefs/db142.htm 3 Halpern NA, Pastores SM, Greenstein RJ. Critical care medicine in the United States 1985–2000: an analysis of bed numbers, use, and costs. Crit Care Med 2004;32:1254–1259. 4 Kox M, Pickkers P. “Less is more” in critically ill patients: not too intensive. JAMA Intern Med 2013;173:1369–1372. 5 Goulart BH, Bensink ME, Mummy DG, Ramsey SD. Lung cancer screening with low-dose computed tomography: costs, national expenditures, and cost-effectiveness. J Natl Compr Canc Netw 2012;10:267–275. 6 Courtright K, Manaker S. Counterpoint: should lung cancer screening by chest CT scan be a covered benefit? No. Chest 2015;147: 289–292. 7 Asch DA, Nicholson S, Srinivas S, Herrin J, Epstein AJ. Evaluating obstetrical residency programs using patient outcomes. JAMA 2009; 302:1277–1283. 8 Weinberger SE. Providing high-value, cost-conscious care: a critical seventh general competency for physicians. Ann Intern Med 2011; 155:386–388. 9 Institute of Medicine. The healthcare imperative: lowering costs and improving outcomes. Washington, DC: National Academies Press; 2009. 10 Institute of Medicine. Crossing the quality chasm. Washington, DC: National Academies Press; 2001. 11 Crosson FJ. Change the microenvironment: delivery system reform essential to controlling costs [accessed 2015 Mar 9]. Available from: http://www.commonwealthfund.org/publications/commentaries/ 2009/apr/change-the-microenvironment 12 Mularski RA, Asch SM, Shrank WH, Kerr EA, Setodji CM, Adams JL, Keesey J, McGlynn EA. The quality of obstructive lung
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13
14
15
16 17 18
19 20 21
22
23
public speaking, and successful collaboration.
Building toward the Future It is essential for training programs to provide a clear pathway for interested trainees to engage in quality improvement and cost-awareness research. As federal funding mechanisms for this type of work are rare, both institutions and professional societies will need to invest in helping talented trainees embrace high-value care as a viable career option within academic medicine. We call on pulmonary and critical care educators to accept this challenge by training future physicians to not only gain competency in high-value care, but to transition toward fulfilling careers that focus on providing the highest quality care possible. n Author disclosures are available with the text of this article at www.atsjournals.org.
disease care for adults in the United States as measured by adherence to recommended processes. Chest 2006;130: 1844–1850. Garland A, Shaman Z, Baron J, Connors AF Jr. Physician-attributable differences in intensive care unit costs: a single-center study. Am J Respir Crit Care Med 2006;174:1206–1210. Tilburt JC, Wynia MK, Sheeler RD, Thorsteinsdottir B, James KM, Egginton JS, Liebow M, Hurst S, Danis M, Goold SD. Views of US physicians about controlling health care costs. JAMA 2013;310: 380–388. Owens DK, Qaseem A, Chou R, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. High-value, cost-conscious health care: concepts for clinicians to evaluate the benefits, harms, and costs of medical interventions. Ann Intern Med 2011;154:174–180. Cassel CK, Guest JA. Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA 2012;307:1801–1802. Costs of Care. Teaching Value Project. [accessed 2015 Jan 5]. Available from: http://teachingvalue.org Institute for Healthcare Improvement. Open school. [accessed 2015 Jan 6]. Available from: http://www.ihi.org/education/ihiopenschool/ overview/pages/default.aspx Hood VL, Weinberger SE. High value, cost-conscious care: an international imperative. Eur J Intern Med 2012;23:495–498. Moriates C, Shah N, Arora VM. Medical training and expensive care. Health Aff (Millwood) 2013;32:196. Dine CJ, Miller J, Fuld A, Bellini LM, Iwashyna TJ. Educating physicians-in-training about resource utilization and their own outcomes of care in the inpatient setting. J Grad Med Educ 2010; 2:175–180. Mehrotra A, Reid RO, Adams JL, Friedberg MW, McGlynn EA, Hussey PS. Physicians with the least experience have higher cost profiles than do physicians with the most experience. Health Aff (Millwood) 2012;31:2453–2463. Sirovich BE, Lipner RS, Johnston M, Holmboe ES. The association between residency training and internists’ ability to practice conservatively. JAMA Intern Med 2014;174:1640–1648.
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OPINIONS AND IDEAS 24 Weinberger SE. Educating trainees about appropriate and costconscious diagnostic testing. Acad Med 2011;86:1352. 25 Detsky AS, Verma AA. A new model for medical education: celebrating restraint. JAMA 2012;308:1329–1330. 26 Weiss KB, Bagian JP, Wagner R. CLER pathways to excellence: expectations for an optimal clinical learning environment (executive summary). J Grad Med Educ 2014;6:610–611. 27 Fessler HE, Addrizzo-Harris D, Beck JM, Buckley JD, Pastores SM, Piquette CA, Rowley JA, Spevetz A. Entrustable professional activities and curricular milestones for fellowship training in pulmonary and critical care medicine: report of a multisociety working group. Chest 2014;146:813–834. 28 Schroeder SA, Myers LP, McPhee SJ, Showstack JA, Simborg DW, Chapman SA, Leong JK. The failure of physician education as a cost containment strategy: report of a prospective controlled trial at a university hospital. JAMA 1984;252:225–230. 29 Miyakis S, Karamanof G, Liontos M, Mountokalakis TD. Factors contributing to inappropriate ordering of tests in an academic medical department and the effect of an educational feedback strategy. Postgrad Med J 2006;82:823–829. 30 Moriates C, Dohan D, Spetz J, Sawaya GF. Defining competencies for education in health care value: recommendations from the University of California, San Francisco Center for Healthcare Value Training Initiative. Acad Med 2015;90:421–424. 31 Moriates C, Soni K, Lai A, Ranji S. The value in the evidence: teaching residents to “choose wisely”. JAMA Intern Med 2013;173:308–310. 32 Smith CD; Alliance for Academic Internal Medicine–American College of Physicians High Value; Cost-Conscious Care Curriculum Development Committee. Teaching high-value, cost-conscious care to residents: the Alliance for Academic Internal Medicine–American
578
33
34
35
36
37
38
39
College of Physicians curriculum. Ann Intern Med 2012;157: 284–286. Halpern SD, Becker D, Curtis JR, Fowler R, Hyzy R, Kaplan LJ, Rawat N, Sessler CN, Wunsch H, Kahn JM; Choosing Wisely Taskforce. An official American Thoracic Society/American Association of CriticalCare Nurses/American College of Chest Physicians/Society of Critical Care Medicine policy statement: the Choosing Wisely® Top 5 list in Critical Care Medicine. Am J Respir Crit Care Med 2014;190: 818–826. Wiener RS, Ouellette DR, Diamond E, Fan VS, Maurer JR, Mularski RA, Peters JI, Halpern SD; Choosing Wisely Taskforce. An official American Thoracic Society/American College of Chest Physicians policy statement: the Choosing Wisely top five list in adult pulmonary medicine. Chest 2014;145:1383–1391. Moriates C, Novelero M, Quinn K, Khanna R, Mourad M. “Nebs No More after 24”: a pilot program to improve the use of appropriate respiratory therapies. JAMA Intern Med 2013;173:1647–1648. Anstey MH, Weinberger SE, Roberts DH. Teaching and practicing costawareness in the intensive care unit: a TARGET to aim for. J Crit Care 2014;29:107–111. Hulley SB, Cummings SR, Browner WS, Grady DG, Newman TB. Designing clinical research, 3rd ed. Philadelphia: Lippincott, Williams, and Wilkins; 2007. Shah N, Levy AE, Moriates C, Arora VM. Wisdom of the crowd: bright ideas and innovations from the Teaching Value and Choosing Wisely Challenge. Acad Med (In press) Caverly TJ, Combs BP, Moriates C, Shah N, Grady D. Too much medicine happens too often: the teachable moment and a call for manuscripts from clinical trainees. JAMA Intern Med 2014; 174:8–9.
AnnalsATS Volume 12 Number 4 | April 2015
Abstract Physician decision making is partially responsible for the roughly 30% of U.S. healthcare expenditures that are wasted annually on lowvalue care. In response to both the widespread public demand for higher-quality care and the cost crisis, payers are transitioning toward value-based payment models whereby physicians are rewarded for high-value, cost-conscious care. Furthermore, to target physicians in training to practice with cost awareness, the Accreditation Council for Graduate Medical Education has created both individual objective milestones and institutional requirements to incorporate quality improvement and cost awareness into fellowship training. Subsequently, some professional medical societies have initiated high-value care educational campaigns, but the overwhelming majority target either medical students or residents in training.
Currently, there are few resources available to help guide subspecialty fellowship programs to successfully design durable high-value care curricula. The resource-intensive nature of pulmonary and critical care medicine offers unique opportunities for the specialty to lead in modeling and teaching high-value care. To ensure that fellows graduate with the capability to practice high-value care, we recommend that fellowship programs focus on four major educational domains. These include fostering a value-based culture, providing a robust didactic experience, engaging trainees in process improvement projects, and encouraging scholarship. In doing so, pulmonary and critical care educators can strive to train future physicians who are prepared to provide care that is both high quality and informed by cost awareness. Keywords: costs; healthcare quality; medical education
(Received in original form January 15, 2015; accepted in final form February 25, 2015 ) The views expressed in this article do not communicate an official position of the American College of Physicians. Correspondence and requests for reprints should be addressed to Jason Wagner, M.D., M.S.H.P., University of Pennsylvania, Philadelphia Veterans Affairs Medical Center, 3900 Woodland Avenue, A811, Philadelphia, PA 19104. E-mail: [email protected] Ann Am Thorac Soc Vol 12, No 4, pp 574–578, Apr 2015 Copyright © 2015 by the American Thoracic Society DOI: 10.1513/AnnalsATS.201501-035OI Internet address: www.atsjournals.org
Presently, the United States invests more resources in healthcare than any other modern nation, but does not achieve better health outcomes (1). This, in part, suggests that the quality of U.S. healthcare can be improved both by minimizing healthcare waste and ensuring that evidence-based strategies are routinely adopted. To that end, medical educators must embrace teaching trainees about high-value care, which can be defined as care that balances clinical benefit with costs and harms in an effort to improve patient-centered outcomes. Failing to practice high-value care poses substantial risks to both patients and
574
society, given that healthcare costs are a common contributor to financial bankruptcy and threaten to impinge upon competing societal interests (2). Consequently, numerous stakeholders are transitioning toward value-based reimbursement models that incorporate pay-for-performance metrics and incentivize physicians to prioritize cost awareness. High-value care is particularly germane to pulmonary and critical care medicine. The intensive care unit (ICU) is a resourceintensive environment (3), where low-value care commonly exists (4), and evidence
frequently lags in its implementation. In addition, in the outpatient setting, pulmonologists are moving toward screening high-risk patients for lung cancer with serial low-dose computed tomography. This is predicted to substantially increase healthcare costs (5), which will only be compounded if providers offer this service to patients who stand little chance of benefitting (6). Teaching cost awareness during fellowship is essential, given that physician prescribing behaviors appear to be linked to training environments and persist long after training is completed (7). This cultural
AnnalsATS Volume 12 Number 4 | April 2015
OPINIONS AND IDEAS imprinting has led some to call on policy makers to place increasing emphasis on teaching future physicians about highvalue care. Specifically, there is interest in aligning funds for graduate medical education with training programs’ abilities to teach cost awareness as a core competency (8). This article outlines the importance of teaching cost awareness in graduate medical education, and provides strategies to incorporate a high-value care curriculum into pulmonary and critical care fellowship training. Our goal is to spark enthusiasm among medical educators to foster experiences that adequately prepare fellows to be stewards of healthcare resources and lead in providing high-value care.
spending hinge on successful engagement of physicians to practice with a high-value mindset. There is a mounting effort to bring cost-of-care discussions out of the executive suite and to the bedside as an everyday component of patient–physician communication. Several physician-targeted initiatives have emerged to implement cost awareness in everyday practice. These include the American College of Physicians’ High Value, Cost-Conscious Care Initiative (15), the American Board of Internal Medicine Foundation’s Choosing Wisely campaign (16), the Costs of Care Teaching Value Project (17), and the Institute for Healthcare Improvement’s Open School (18).
The Role of Physicians in Determining Value
The Responsibility of Teaching High-Value Care to Trainees
Over a decade ago, the Institute of Medicine published a series of reports that served as a clarion call for physicians to improve healthcare quality, and to resist a laissezfaire response to the untenable costs that stem from the routine waste of healthcare resources (9, 10). Accordingly, physicians play a pivotal role in the success of a valuebased system, as they account for about 80% of healthcare expenditures (11), and are an important source of waste via prescribing nonbeneficial treatments and over-using diagnostic testing. Pulmonary and critical care providers are not exempt from the responsibility to provide appropriate care. For example, patients with chronic obstructive pulmonary disease receive only 55% of recommended care (12), and there is variation in intensivists’ resource utilization patterns without a notable improvement in patient outcomes (13). In a large survey of U.S. physicians, only 27% of respondents felt they had a major responsibility to reduce costs. Instead, physicians felt that lawyers, insurers, pharmaceutical companies, and even patients shouldered this responsibility (14). Interestingly, they also felt that physicians should lead in limiting the overuse of services. Although this may reflect the tension inherent in simultaneously serving individual patients and society, it may also represent that physicians are in denial about how their medical decision making contributes to excess costs. Thus, strategies to reign in
There is a hidden curriculum in medical education that rewards trainees to be poor stewards of healthcare resources. Too often, educators prioritize excessive diagnostic testing in pursuit of an all-encompassing differential diagnosis rather than arriving at the correct diagnosis in an evidence-based and cost-conscious fashion (19, 20). Our patients are literally paying the price. Unfortunately, physicians in training often lack knowledge of the actual cost of care that they provide (21), which may at least partially explain why less-experienced physicians appear to have higher cost profiles compared with their more experienced counterparts (22). Although this also may be explained by different training sites (23) or payment models (22), behaviors learned in post-graduate training should not be overlooked as significant contributors to excessive resource utilization (20). We believe that much of the onus falls on medical educators to teach trainees how to embark on cost-conscious diagnostic and treatment plans (20, 24, 25). In 2011, one of the authors of this article proposed that cost awareness become the seventh general competency of the Accreditation Council for Graduate Medical Education (ACGME) to reinforce the importance of teaching high-value care to medical trainees (8). Subsequently, the ACGME established the Clinical Learning Environment Review Pathways to Excellence, a framework designed to
Opinions and Ideas
improve trainees’ facility with patient safety and quality improvement (26). Under the revised ACGME program accreditation process for fellowship programs, curricular milestones are used to assess the development of trainees across six core competencies. The most recent iteration includes an explicit objective for “incorporating cost-awareness and risk– benefit analysis into patient care” (27). Accordingly, a graduated fellow is expected to “improve the quality and safety of health care at both the individual and system levels” without supervision (27).
Strategies for Teaching High-Value Care Past cost-awareness educational interventions targeted at physicians yielded modest results at best (28, 29). This should not be justification to passively accept the status quo. Instead, programs should be actively engaged in adopting, creating, and testing high-value curricula. To do so, we recommend that fellowship programs focus on four major educational domains: fostering a value-based culture, providing a robust didactic experience, engaging trainees in process improvement projects, and encouraging scholarship. Fostering a Value-Based Culture
Fellowship programs must provide a durable training experience that celebrates cost restraint as opposed to a “moreis-better” approach. To provide rigorous training experiences, programs should begin by embracing a value-based philosophy to appropriately model a highvalue mindset for their trainees. Successful modeling can occur by asking fellows to reflect on how they may be over-using resources and then encouraging them to adopt a “less-is-more” approach when appropriate. In addition, programs should train and support interested faculty to develop successful multifaceted curricula. As with any topic in medicine, faculty expertise and role modeling of desired behavior are prerequisites for changing the culture in the training environment. We believe that professional societies can play a key role in “training the trainers” by developing educational resources that help to facilitate expertise among a growing number of interested faculty. 575
OPINIONS AND IDEAS Although integrating costs in a transparent manner to provide real-time feedback is a valuable way to target physicians in training, many institutions lack the sophistication in their electronic medical record to do so. If capable, we recommend leveraging this “dashboard” technology to provide longitudinal feedback to fellows about their resource utilization patterns. For those programs that do not have this ability, there are still creative ways to promote cost awareness. One simple way to promote high-value care without access to real-time cost data is to improve fellows’ medical decisions by teaching them to order fewer initial diagnostic tests. Although programs largely succeed in training fellows to master comprehensive differential diagnoses, they often fall short on teaching fellows to arrive at a correct diagnosis in a cost-conscious manner. To do so, we recommend the following framework. First, assist fellows to generate a complete differential diagnosis to expand their fund of knowledge. Then, have fellows split this differential diagnosis into three categories: (1) diagnoses that are likely; (2) diagnoses that are less likely, but dangerous to miss; and (3) diagnoses that are less likely and do not warrant emergent investigation. Next, encourage them to pursue an evidence-based diagnostic approach for only the first two categories. Instruct them to only revisit the third category if their initial diagnostic assumptions were incorrect. Modeling medical decision making in this manner reinforces that, although it is important to develop an all-inclusive differential diagnosis, it is wasteful to execute a “shotgun approach” that aggressively attempts to evaluate every diagnosis with a low pretest probability. Providing a Robust Didactic Experience
Several resources for value-driven didactics now exist for medical educators. The University of California, San Francisco, Center for Healthcare Value Training Initiative recently defined a comprehensive set of applicable high-value care competencies aimed at setting a curricular standard for all stages of professional training (30). At that same institution, they implemented a case-based high-value care curriculum that was well received by medicine residents, although outcome measures have not yet been reported (31). In a cost-awareness pilot initiative, The 576
University of Pennsylvania showed that the combination of structured didactics and real-time comparative feedback was feasible for assessing high-value care practices among trainees (21). On a larger scale, a core educational initiative of the American College of Physicians is their High-Value Care Curriculum (32). It is composed of short, case-based sessions that employ a detailed five-step framework for physicians in training to develop a high-value care skillset. For pulmonary and critical care program directors, we recommend assessing incoming fellows to determine if they have completed this coursework in their residency training, and to consider incorporating this curriculum into the didactic schedule early in the first year of fellowship if necessary. Although the cases use internal medicine examples to highlight six topics surrounding healthcare value, one could easily imagine how exchanging cases focused on the pulmonary and critical care “top five” Choosing Wisely lists (33, 34), for example, could effectively tailor this approach for a fellowship curriculum. In addition, the Institute for Healthcare Improvement launched Open School, an online program to advance the healthcare improvement competencies of the next generation of physicians (18). This webbased curriculum offers free access to a range of courses in patient safety, quality improvement, and cost awareness, and provides certification of completion. Alternatively, a fee-based subscription is available to organizations interested in tracking a learner’s progress and performance through the course. This has the advantage of providing a flexible curriculum that fellows can complete on their own, while simultaneously allowing programs to gauge trainees’ development. Institutions should capitalize on faculty expertise in this area, if possible, to expose fellows to key concepts. For example, in response to the most recent iteration of ACGME milestones and Clinical Learning Environment Review, our fellowship program created a 2-year longitudinal curriculum that begins with didactic lectures that occur early in the first year and culminates with fellows conducting their own process improvement projects. The lecture topics address how to promote a culture of patient safety, fundamental concepts and tools used to conduct process improvement projects, and high-value
care principles that emphasize how cost reductions can result in improved safety and quality. Before developing their process improvement project, each first-year fellow leads a multidisciplinary morbidity and mortality conference in which he or she presents a case vignette that highlights a need for process improvement. The fellow then meets with faculty leadership to conduct a root cause analysis. This approach provides fellows with an early recognition of the importance of high-value care and prepares them for the next phase of their system-based training. Engaging Trainees in Process Improvement Projects
There are several ways to engage fellows to facilitate cost awareness. One powerful way is to have them design and conduct process improvement projects. For example, physicians at the University of California, San Francisco successfully reduced resident ordering of costly nebulized therapies for hospitalized patients through a pilot educational program called “Nebs No More after 24.” They saved roughly $250,000 annually and improved quality by shifting respiratory therapists’ time away from providing low-value therapy toward instructing patients on proper inhaler technique (35). In critical care medicine, a “less is more” approach often results in superior outcomes (4). Recently, an ICU-specific framework for teaching and promoting high-value care was developed (36). This framework is composed of six elements that spell out the aptly named mnemonic, TARGET, to encourage busy ICU physicians to pause for consideration of these high-value care practices. The specific components are: talk to patients about their preferences, ask for outside tests, avoid routine and/or repeated tests, prescribe generic medications, educate about costs, and transfuse appropriately (36). Involving fellows in value-based process improvement projects is an effective way to provide experiential learning that can be captured by training programs to longitudinally assess trainees’ progression. To do so, programs should partner with existing hospital leadership in quality improvement to select projects that are aligned with institutional priorities. Furthermore, we recommend that programs assist fellows to select projects that fulfill the “FINER” criteria (37). Within pulmonary and critical care
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OPINIONS AND IDEAS medicine there are several areas of potential interest to merge process improvement with high-value care. Examples include improving the degree to which your institution’s specialty is “choosing wisely,” identifying over-utilized resources (e.g., computed tomography angiography, echocardiography, and pulmonary function testing in the absence of respiratory symptoms) and devising action plans to decrease utilization, and evaluating patterns of care transitions. Medical educators can accelerate the high-value care movement by creating and disseminating curricular innovations. For example, in a recent joint venture between the American Board of Internal Medicine Foundation and Costs of Care, the “Teaching Value and Choosing Wisely Challenge” used crowdsourcing to solicit a diverse number of accessible approaches to teaching high-value care that are generalizable to training programs (38). Encouraging Scholarship
Fellows should be provided with training experiences that build their knowledge,
provide them with opportunities to conduct process improvement projects, and assist them in producing scholarly work. Depending on the scope of the project, highvalue care scholarship can be submitted as a perspective piece centered on a case vignette (39), as an abstract describing innovations in fellowship education, or as a manuscript to journals that publish quality improvement projects or assessments of novel curricula. For the advanced research fellow, scholarship can include improving the methodology of implementation science, randomized trials of quality improvement interventions, and cost–benefit analyses. Akin to successful research training programs, we encourage fellowship programs to foster a supportive environment to assist trainees in carrying out value-based scholarship. This includes both work-in-progress sessions, where trainees can present their work to receive useful feedback about the design and execution of their projects, and dedicated mentorship to develop important academic skills, such as scientific writing,
References 1 OECD. Health at a glance. 2013 [accessed 2014 Jan 11]. Available from: http://www.oecd.org/els/health-systems/health-at-aglance-2013.pdf 2 Cohen RA, Kirzinger WK. Financial burden of medical care: a family perspective [updated 2014 Jan 28; accessed 2015 Mar 24]. Available from: http://www.cdc.gov/nchs/data/databriefs/db142.htm 3 Halpern NA, Pastores SM, Greenstein RJ. Critical care medicine in the United States 1985–2000: an analysis of bed numbers, use, and costs. Crit Care Med 2004;32:1254–1259. 4 Kox M, Pickkers P. “Less is more” in critically ill patients: not too intensive. JAMA Intern Med 2013;173:1369–1372. 5 Goulart BH, Bensink ME, Mummy DG, Ramsey SD. Lung cancer screening with low-dose computed tomography: costs, national expenditures, and cost-effectiveness. J Natl Compr Canc Netw 2012;10:267–275. 6 Courtright K, Manaker S. Counterpoint: should lung cancer screening by chest CT scan be a covered benefit? No. Chest 2015;147: 289–292. 7 Asch DA, Nicholson S, Srinivas S, Herrin J, Epstein AJ. Evaluating obstetrical residency programs using patient outcomes. JAMA 2009; 302:1277–1283. 8 Weinberger SE. Providing high-value, cost-conscious care: a critical seventh general competency for physicians. Ann Intern Med 2011; 155:386–388. 9 Institute of Medicine. The healthcare imperative: lowering costs and improving outcomes. Washington, DC: National Academies Press; 2009. 10 Institute of Medicine. Crossing the quality chasm. Washington, DC: National Academies Press; 2001. 11 Crosson FJ. Change the microenvironment: delivery system reform essential to controlling costs [accessed 2015 Mar 9]. Available from: http://www.commonwealthfund.org/publications/commentaries/ 2009/apr/change-the-microenvironment 12 Mularski RA, Asch SM, Shrank WH, Kerr EA, Setodji CM, Adams JL, Keesey J, McGlynn EA. The quality of obstructive lung
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public speaking, and successful collaboration.
Building toward the Future It is essential for training programs to provide a clear pathway for interested trainees to engage in quality improvement and cost-awareness research. As federal funding mechanisms for this type of work are rare, both institutions and professional societies will need to invest in helping talented trainees embrace high-value care as a viable career option within academic medicine. We call on pulmonary and critical care educators to accept this challenge by training future physicians to not only gain competency in high-value care, but to transition toward fulfilling careers that focus on providing the highest quality care possible. n Author disclosures are available with the text of this article at www.atsjournals.org.
disease care for adults in the United States as measured by adherence to recommended processes. Chest 2006;130: 1844–1850. Garland A, Shaman Z, Baron J, Connors AF Jr. Physician-attributable differences in intensive care unit costs: a single-center study. Am J Respir Crit Care Med 2006;174:1206–1210. Tilburt JC, Wynia MK, Sheeler RD, Thorsteinsdottir B, James KM, Egginton JS, Liebow M, Hurst S, Danis M, Goold SD. Views of US physicians about controlling health care costs. JAMA 2013;310: 380–388. Owens DK, Qaseem A, Chou R, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. High-value, cost-conscious health care: concepts for clinicians to evaluate the benefits, harms, and costs of medical interventions. Ann Intern Med 2011;154:174–180. Cassel CK, Guest JA. Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA 2012;307:1801–1802. Costs of Care. Teaching Value Project. [accessed 2015 Jan 5]. Available from: http://teachingvalue.org Institute for Healthcare Improvement. Open school. [accessed 2015 Jan 6]. Available from: http://www.ihi.org/education/ihiopenschool/ overview/pages/default.aspx Hood VL, Weinberger SE. High value, cost-conscious care: an international imperative. Eur J Intern Med 2012;23:495–498. Moriates C, Shah N, Arora VM. Medical training and expensive care. Health Aff (Millwood) 2013;32:196. Dine CJ, Miller J, Fuld A, Bellini LM, Iwashyna TJ. Educating physicians-in-training about resource utilization and their own outcomes of care in the inpatient setting. J Grad Med Educ 2010; 2:175–180. Mehrotra A, Reid RO, Adams JL, Friedberg MW, McGlynn EA, Hussey PS. Physicians with the least experience have higher cost profiles than do physicians with the most experience. Health Aff (Millwood) 2012;31:2453–2463. Sirovich BE, Lipner RS, Johnston M, Holmboe ES. The association between residency training and internists’ ability to practice conservatively. JAMA Intern Med 2014;174:1640–1648.
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OPINIONS AND IDEAS 24 Weinberger SE. Educating trainees about appropriate and costconscious diagnostic testing. Acad Med 2011;86:1352. 25 Detsky AS, Verma AA. A new model for medical education: celebrating restraint. JAMA 2012;308:1329–1330. 26 Weiss KB, Bagian JP, Wagner R. CLER pathways to excellence: expectations for an optimal clinical learning environment (executive summary). J Grad Med Educ 2014;6:610–611. 27 Fessler HE, Addrizzo-Harris D, Beck JM, Buckley JD, Pastores SM, Piquette CA, Rowley JA, Spevetz A. Entrustable professional activities and curricular milestones for fellowship training in pulmonary and critical care medicine: report of a multisociety working group. Chest 2014;146:813–834. 28 Schroeder SA, Myers LP, McPhee SJ, Showstack JA, Simborg DW, Chapman SA, Leong JK. The failure of physician education as a cost containment strategy: report of a prospective controlled trial at a university hospital. JAMA 1984;252:225–230. 29 Miyakis S, Karamanof G, Liontos M, Mountokalakis TD. Factors contributing to inappropriate ordering of tests in an academic medical department and the effect of an educational feedback strategy. Postgrad Med J 2006;82:823–829. 30 Moriates C, Dohan D, Spetz J, Sawaya GF. Defining competencies for education in health care value: recommendations from the University of California, San Francisco Center for Healthcare Value Training Initiative. Acad Med 2015;90:421–424. 31 Moriates C, Soni K, Lai A, Ranji S. The value in the evidence: teaching residents to “choose wisely”. JAMA Intern Med 2013;173:308–310. 32 Smith CD; Alliance for Academic Internal Medicine–American College of Physicians High Value; Cost-Conscious Care Curriculum Development Committee. Teaching high-value, cost-conscious care to residents: the Alliance for Academic Internal Medicine–American
578
33
34
35
36
37
38
39
College of Physicians curriculum. Ann Intern Med 2012;157: 284–286. Halpern SD, Becker D, Curtis JR, Fowler R, Hyzy R, Kaplan LJ, Rawat N, Sessler CN, Wunsch H, Kahn JM; Choosing Wisely Taskforce. An official American Thoracic Society/American Association of CriticalCare Nurses/American College of Chest Physicians/Society of Critical Care Medicine policy statement: the Choosing Wisely® Top 5 list in Critical Care Medicine. Am J Respir Crit Care Med 2014;190: 818–826. Wiener RS, Ouellette DR, Diamond E, Fan VS, Maurer JR, Mularski RA, Peters JI, Halpern SD; Choosing Wisely Taskforce. An official American Thoracic Society/American College of Chest Physicians policy statement: the Choosing Wisely top five list in adult pulmonary medicine. Chest 2014;145:1383–1391. Moriates C, Novelero M, Quinn K, Khanna R, Mourad M. “Nebs No More after 24”: a pilot program to improve the use of appropriate respiratory therapies. JAMA Intern Med 2013;173:1647–1648. Anstey MH, Weinberger SE, Roberts DH. Teaching and practicing costawareness in the intensive care unit: a TARGET to aim for. J Crit Care 2014;29:107–111. Hulley SB, Cummings SR, Browner WS, Grady DG, Newman TB. Designing clinical research, 3rd ed. Philadelphia: Lippincott, Williams, and Wilkins; 2007. Shah N, Levy AE, Moriates C, Arora VM. Wisdom of the crowd: bright ideas and innovations from the Teaching Value and Choosing Wisely Challenge. Acad Med (In press) Caverly TJ, Combs BP, Moriates C, Shah N, Grady D. Too much medicine happens too often: the teachable moment and a call for manuscripts from clinical trainees. JAMA Intern Med 2014; 174:8–9.
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