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.
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.
- Jessica Dine, KeryLyn Gwisdalla, Darilyn Moyer, Jason Post and Sara Wallach: http://bit.ly/ZPZLfs
- Soni and S. Ranji: https://medicine.ucsf.edu/safety/education/qipscurricularblueprint.pdf