Skip to main content
High-Value Care: An essential concept in residency education

High-Value Care: An essential concept in residency education

In both Canada and the US, controlling rising health care costs are considered national priorities. The genesis of these rising costs is multi-factorial, and includes important issues such as the aging demographic, increases in the use of costly technologies, the increasingly expensive cost of in-patient hospital care, and the costs of drugs. There is a consensus that many of the expenditures emanating from the ordering of tests may not be warranted. In the U.S., estimates of these “wasted costs” are staggering and may account for over $700 billion of annual expenditures on a total health care spend of $3.8 trillion.1,2

Recently a High Value Care Curriculum (HVC) for residents in medical training has been jointly developed by the American College of Physicians (ACP) and the Alliance for Academic Internal Medicine (AAIM). This curriculum is aimed at augmenting the teaching of residents in areas of cost containment and evidence-based test ordering.3 In addition to test ordering, the curriculum covers the use of biostatistics in diagnosis, screening and prevention, medication ordering, and quality improvement.

An excellent powerpoint presentation is available online, as is a curricular blueprint used at UCSF.4,5

These efforts fortify what is a growing movement in both the U.S. and Canada, namely Choosing Wisely.6 This is a “campaign to help physicians and patients engage in conversations about unnecessary tests, treatments and procedures”.6 The foundation on which Choosing Wisely has been built is to get consensus on decisions that patients and their doctors make together. Many medical societies have developed the ‘five most important questions to ask’ in their area of expertise. For example, the five important questions about care in an emergency department, as published by the American College of Emergency Physicians (ACEP) 2013 Scientific Assembly are:7

  • For patients with minor head injury who are deemed to be at low risk for skull fractures or hemorrhage, based on validated decision rules, clinicians should avoid head computed tomography scans. The majority of minor head injuries do not result in brain hemorrhage.
  • For stable patients who can urinate on their own, clinicians should avoid placing indwelling urinary catheters for either urine output monitoring or patient or staff convenience.
  • For patients likely to benefit from palliative and hospice care services, clinicians should not delay in engaging such services when available. Early referral from the emergency department can improve quality, as well as quantity, of life.
  • For patients with uncomplicated skin and soft tissue abscesses successfully treated with incision and drainage, clinicians should provide adequate medical follow-up but avoid antibiotics and wound cultures.
  • For children with mild to moderate, uncomplicated dehydration, clinicians should avoid giving intravenous fluids before a trial of oral rehydration therapy.

It is critical for all medical educators to include issues of cost containment (high value care) in their teaching. A recent white paper on Professionalism from the Royal College of Physicians and Surgeons of Canada reinforced this responsoibility.8

Teaching cost-containment to residents is not new; there have been programs dating back to the 80s.9 However, it can be argued that it is now imperative to graduate a cadre of cost-conscious physicians who are dedicated to high-value care. If we, as Canadians, want to sustain our current system which promotes universality as a fundamental principle, this type of care is essential.

If you have any thoughts about high-value care, respond to the blog, or better yet, please drop by the Macklem House, my door is always open.

Richard

 

  1. http://www.forbes.com/fdc/welcome_mjx.shtml
  2. http://www.ncbi.nlm.nih.gov/pubmed/22777503
  3. https://hvc.acponline.org/curriculum.html
  4. Jessica Dine, KeryLyn Gwisdalla, Darilyn Moyer, Jason Post and Sara Wallach: http://bit.ly/ZPZLfs
  5. Soni and S. Ranji: https://medicine.ucsf.edu/safety/education/qipscurricularblueprint.pdf
  6. http://www.choosingwiselycanada.org/
  7. http://www.medscape.com/viewarticle/812600
  8. http://www.royalcollege.ca/portal/page/portal/rc/common/documents/educational_initiatives/professionalism.pdf
  9. http://www.ncbi.nlm.nih.gov/pubmed/6471083

Susan Pine

Wed, 07/05/2017 - 14:42

Hi Richard.
I enjoyed your blog very much and it triggered another thought about Health Professionals and costs.
My son was in isolation in hospital a year ago and I watched in horror as all kinds of extra dressing and IV supplies were brought into his room knowing full well that it would all be discarded on his discharge. It made me think was it a lack of training in organizational skills I.e. just grabbing a variety of things “just in case” instead of planning around the task at hand and the supplies needed. Or, was it more about not being conscious of what the supplies that we use daily actually cost and because it doesn’t comie out of our own pockets, so to speak, we are not “informed consumers” and therefore do not practise comparison shopping or look at how we can save on the bottom line.
As you have pointed out, the escalating cost of health care should be a concern to all of us. I think it would be a very interesting scenario to present each of us with an invoice at the end of our day outlining how much we had spent. I have a feeling many of us would be horrified!
Cheers.

Susan Pine

reznickr

Wed, 07/05/2017 - 14:42

In reply to by student

Dear Susan,

I agree entirely. In fact, I believe there is research on this issue that would support your contention that real time feedback of the costs of tests and supplies to physicians results in better cost containment. Thanks for your comments.

Richard

reznickr

John S. Rodway, M.D. Queens Class of '68 President Central Florida Queens Alumni

Wed, 07/05/2017 - 14:42

My concern here in Florida and elsewhere in the USA this could easily result in malpractice awards of very high amounts when the jury feels sympathy for a less than optimal outcome where in retrospect a CAT scan or other test might/would have changed the treatment, even though the protocol not to do a CAT scan was adhered to.
Without laws protecting the physician I am opposed to this approach, and cognizant that politically the trial lawyers association is very politically powerful and would be successful in blocking any such legislation.
In Florida, a cap on malpractice award was overturned by the Florida Supreme court.

John S. Rodway, M.D. Queens Class of '68 President Central Florida Queens Alumni

Dear John,

You correctly point out that the pressures regarding these issues differ from state to state and indeed across countries. We are fortunate in Canada that we have more or less one national standard and all physicians belong to a single self- insurance association, the CMPA. CMPA is quite aggressive in fighting frivolous claims.

Richard

reznickr

Allan Spear Queens Meds 60

Wed, 07/05/2017 - 14:43

part of our resident training in Baltimore in the 60s was to be given a printout of the patients tests and treatment costs, this to me was a big eye opener and has influenced my entire career in practice

Allan Spear Queens Meds 60

Michael

Wed, 07/05/2017 - 14:44

I agree that providing an invoice to a client and/or physician is one way to bring awareness to the rising cost of healthcare, however the opportunity to make an impact is lost.

I worked at a hospital which had a novel idea of labeling each individual item on a dressing supply cart with its price. I was shocked to learn some of the prices and it encouraged me to conserve by thinking through the amount of supplies required prior to the dressing being changed.

Similar to a grocery store, all resources in healthcare should have a current price available prior to consumption in order to influence the healthcare provider’s decision on the resources required to care for the client.

Michael

Michael

Diane

Wed, 07/05/2017 - 14:44

Dear Dean Resnick,

High value care is also a concern for other professionals who are also caring for wounds, ordering blood work and tests as well as prescribing and coordinating resources for patients ie dietitians, pharmacists, physiotherapists, nurses and nurse practitioners. An inter professional approach to educating personnel and working on a solution will bring creative decisions to the forefront while involving all in a team effort to implement cost containment strategies.

Diane

Diane

Dear Diane,

I agree 100% that this would be a good topic for interprofessional learning and practice. Thanks for highlighting this issue

Richard

reznickr

Mary Dunn

Wed, 07/05/2017 - 14:45

Greetings from one British trained hospital nurse.

In 1976, whilst doing a practicum prior to obtaining my Canadian registration as an RN i cared for a patient on 2 antibiotics, a stinking wound from recent surgery, and the only saline available to clean it was IV saline. Surely a waste of resources.
The patient was delighted to be free of the stench, and this with a nurse without a University degree.

Recently I had occasion to know someone with a longstanding, 5 year pulmonary lesion. Without complete review of previous CT scans, she was ordered a brain scan, abdominal scan, bronchoscopy, bone scan, lung biopsy and a PT scan 10 days after the biopsy. As there was increased activity noted in the latter she was refereed to Chest surgery and had another 2 chest CT scans. All results were possible malignancy, indeterminate or exclude malignancy. Should tests not be ordered sequentially starting with the least invasive and most cost effective? I do realise the legal dangers of “not doing everything”
Regards
Mary Dunn RN

Mary Dunn

Dear Mary,

Thanks fo bringing up two important points. With respect to the use of IV saline, I would have used it too! Sometimes practicality outweighs “standard operating procedures”. Regarding your comment about non- baccalaureate trained nurses, some of the greatest nurses I ever worked with fall into that designation.

With regards to the story you relate regarding over-investigation of a pulmonary finding, I agree with you 100%. Indeed, we, as health care professionals, must be vigilant custodians of the public purse.

Thanks for your comments,

Richard

reznickr

Add new comment

Plain text

  • No HTML tags allowed.
  • Lines and paragraphs break automatically.
  • Web page addresses and email addresses turn into links automatically.