Improving Residents’ Skills for Providing High Value Care Through a Curricular Innovation: A Cost Conscious - Clinical

Reasoning Conference (CC-CRC) Kavitha Kesari MD, MS, FACP;

Shagufta Ali MD, FACP Susan J. Smith MD, FACP

Kavitha.kesari@mclaren.org (810)342 3063

10/24/2014

The Disclosure

Educational Innovative Method

National Need • US - 30% of healthcare costs (more than $750

billion annually) are spent on wasted care • Canada spends ≤ U.S. by $1,589 per capita • Physician’s professional responsibility

– Use healthcare resources judiciously – Keep the individual patient in focus – Need: training about healthcare costs

* Pozen A, Eckstein D. Medical Spending Differences in the United States and Canada: The Role of Prices, Procedures, and Administrative Expenses, 2002

Objectives and Goals*

• To increase residents’ knowledge of healthcare’s value, quality, and cost metrics

Increase Knowledge

• To improve trainees attitudes regarding high value care by discussing Clinical Cases

Improve Attitudes

• Cultivate and sustain more cost-effective physician ordering behaviors Skills

*ACP-AAIM High value cost conscious care curriculum

ACGME

• Milestones Linked to Systems-Based Practice • Understand and apply cost-benefit analysis • Identify health care stakeholders and their impact

on cost of, and access to, health care • Identify costs for common diagnostic tests and

treatment • Minimize unnecessary care • Demonstrate incorporation of cost-awareness

into standard clinical decision-making

CANMEDS

HEALTH ADVOCATE • Demonstrate patient advocacy for beneficial

services and resources (EBM) • Facilitate timely patient access to services and

resources

HEALTH CANMEDS ADVOCATE • Advocate for

beneficial services or resources

• Timely patient access services and resources

Systems-Based Practice • Cost-benefit analysis • Various health care

stakeholders • Identify costs • Minimize unnecessary

care • Cost-awareness

principles

M I L E S T O N E s

CANMEDS/ ACGME

VALUE = Health Outcomes/Cost

Background

• Last year, we implemented ACP's High Value, Cost Conscious Care (HVCCC) as formal curriculum.

• IM residents participated in interactive case-based workshops and didactic sessions

HVCC CIRRICULUM

Workshop Didactic sessions

CC-CRC

Clinical Reasoning Conference

Introducing High Value Care

Teams structure

Case History and physical

exam findings are disclosed sequentially

Team 1 Team 2

Methods

• CRC - progressive disclosure of a case in response to residents’ – hypothesis-driven questions

• Analytical, conscious

– pattern recognition • Non-analytical, unconscious

Case Presentation Chief Complaint*

Mental Representation History/ PE/

Diagnostic WU Hypothesis tested

Analytic ↔ Non-analytic

*Eva K.What every teacher needs to know about clinical reasoning. Medical Education 2004:39:98106

In Brief

• History and physical exam findings are disclosed sequentially

• Two resident teams compete • Each has PGY-1 through PGY-3 residents • Teams selectively choose tests to confirm or

disprove diagnostic impressions

Methods

• Health Care Blue Book* residents choose diagnostic tests – evidence – cost and – diagnostic yield (using HVCCC)

• The team that diagnoses the condition at the least cost wins

*The Healthcare Bluebook is a guide to help you determine Fair Prices in your area for

healthcare services.

Concludes with Case Discussion

• Reviews the Case-Salient Features • Differential Diagnosis • Costs and Diagnostic yield • Risks of various tests and procedures

Survey Questions SA A N D SD

1. I am able to effectively use history and physical examination skills to minimize the need for further diagnostic testing

2. I am able to recognize and account for the unique characteristics of a patient while trying to generate a differential diagnosis

3. I am able to incorporates cost-awareness principles into standard clinical judgments and decision-making, including screening tests

4. I am able to understand the concepts of pre-test probability and test performance characteristics

5. I am able to interprets complex diagnostic tests accurately

6. I am able to assess potential costs to the patient when ordering tests

7. I am able to assess the costs to the health care system when ordering tests

8. I am able to fully understand the rationale and risks associated with common diagnostic imaging/procedures

9. I am able to understand how test results will affect management

10. I will incorporate HVC principles in my future practice

Resident’s Reflection about the Impact of Cost-Conscious CRC on their daily clinical practice

SA-Strongly Agree, A- Agree N- Neutral D- Disagree SD- Strongly Disagree

Results

8 8

7

6 6 6

5

7 7

11

7 7 7

5 5 5

7

6

7

4

1

3

4

3

2 2

1 1 1 1

0

2

4

6

8

10

12

Q 1 Q 2 Q 3 Q 4 Q 5 Q 6 Q 7 Q 8 Q 9 Q 10

Cost Conscious Care CRCs

Strongly Agree

Agree

Neutral

Disagree

StronglyDisagree

Summary

• We modified our CRC – competition – evidence-based teaching – awareness of cost-consciousness – high value care – Our CC-CRC reinforces the Can MEDS framework

and the ACGME competencies.

Thank you

Can MEDS framework ACGME competencies

• Medical Knowledge • Patient Care • Professionalism • Interpersonal &

Communication Skills • Practice-based Learning • System based learning